Impact of Preoperative Bowel Preparation on the Risk of Clostridium Difficile after Colorectal Surgery: A Propensity Weighted Analysis

Transcription

1 Impact of Preoperative Bowel Preparation on the Risk of Clostridium Difficile after Colorectal Surgery: A Propensity Weighted Analysis Ebram Salama, MD PGY-3 General Surgery Sir Mortimer B. Davis Jewish General Hospital, McGill University Presenting on behalf of Maria Abou Khalil, MD Maria Abou Khalil, Ebram Salama, Sahir Bhatnagar, Jad Abou Khalil, Carol-Ann Vasilevsky, Gabriela Ghitulescu, Julio Faria, Marylise Boutros

2 None Disclosures

3 Introduction Clostridium difficile infection (CDI) remains an important complication after colorectal surgery CDI significantly increased morbidity and mortality Risk factors CDI: Abdominal surgery Antibiotic use Age Immunosuppression

4 Preoperative Oral Antibiotic Preparation Literature has come full circle with regards to its benefits in decreasing postoperative complications (specifically with regards to surgical site infections) Unclear what the effect of preoperative oral antibiotic preparation is on the rates of postoperative CDI Wren et al. (2005): retrospective review 304 patients Increase in risk of postop CDI Kaprohl et al, Kim et al, Englesbe et al: no association/decreased risk of postoperative CDI

5 Objectives Primary aim: evaluate the effect of bowel preparation on CDI following colorectal surgery Bowel preparation C. Difficile infection Secondary aim: assess the impact of CDI on length of stay and readmission

6 Methods Patients who underwent colorectal surgery selected from ACS-NSQIP database (colectomy-specific files): Postoperative CDI added in 2015 Preoperative diagnosis of CDI or missing outcome data: excluded

7 Methods Primary outcome: Inverse probability weighting regression adjustment used to account for the probability of receiving preoperative bowel preparation Balancing groups for: Albumin, WBC, stoma, age, BMI, diabetes, smoking, independent status, preoperative ventilation, ascites, CHF, HTN, disseminated cancer, IMS, weight loss, bleeding disorder, emergency surgery, wound classification, ASA, approach, sex, preoperative sepsis, indication, preoperative infection, renal disease, preoperative transfusion Secondary outcome: Propensity score weight adjusted linear (length of stay) and logistic (readmission) models Balancing groups for: Albumin, WBC, stoma, age, BMI, diabetes, smoking, independent status, pre-operative ventilation, ascites, CHF, HTN, disseminated cancer, IMS, weight loss, bleeding disorder emergency, wound classification, ASA, approach, sex, pre-op sepsis, postop sepsis/infection, pre-op infection, pre-op renal disease, type of prep received.

8 Results patients included Overall CDI: 1.6% No bowel prep: 1.8% Mechanical prep: 2.2% Oral prep: 1.5% Combined oral+mechanical 1.1% Median LOS (days) for patients with C. Diff infection: 8(5,14) vs. 5 (3,7) Readmission: 30% vs. 9%, p<0.01 Distribution of bowel preparation 38% 39% 5% 18% Combined oral/mechanical Oral Mechanical No BP

9 Outcomes Risk of C diff: Combined prep: decreased probability of postoperative CDI by 33% (p=0.03) Not observed for other bowel preparation regimens Effect of CDI on Length of stay: Increase in LOS by 9.7 days (95%CI ) Effect of CDI on readmission OR 3.39 (95%CI )

10 Strengths and Weaknesses Strengths Multi-institutional, validated database RCT not feasible, however rigorous statistical methodology was used including propensity analysis to balance groups and evaluate effect of bowel preparation on CDI Limitations Unable to specifically account for important risk factors for CDI such as prior CDI, type of antibiotic used, and duration of antibiotics given Limited available data on treatment received for CDI

11 Conclusion Oral and mechanical bowel preparation decreased the risk of postoperative CDI in this large multi-institutional surgical prospective database CDI had significant effects on increased length of stay and readmission

12 References Wren SM, Ahmed N, Jamal A, Safadi BY. (2005). Preoperative oral antibiotics in colorectal surgery increase the rate of Clostridium difficile colitis. Arch Surgery. 140: Kaprohl GL, Phillips L, Campbell DA, e al. (2011). Bowel preparation for colectomy and risk of clostridium difficile infection. Dis Colon Rectum. 54(7): Kim EK, Sheetz KH, Bonn J, et al. (2014). A statewide colectomy experience: the role of full bowel preparation in preventing surgical site infection. Annals of Surgery. 259(2): Englesbe MJ, Brooks L, Kubus J, et al. (2010). A statewide assessment of surgical site infection following colectomy: the oral of antibiotics. Annals of Surgery. 252(3):