C Diff Risk Explored Following Pediatric Appendicitis Procedures

Felix Orelaru, MD

New research suggests pediatric appendicitis patients are more likely to suffer from an additional Clostridium difficile (C diff) infection (CDI).

A team, led by Felix Orelaru, MD, St. Joseph Mercy Hospital, estimated the impact C diff infections have on complications following pediatric acute appendicitis.

It is well known and common that C diff infections can cause nosocomial infections in pediatric populations.

The Study

In the study, the researchers combined data from the 2009 and 2012 Kids’ Inpatient Database and weighted statistical analysis using Survey Sampling and Analysis procedures in SAS 9.4.

Overall, there were 176,934 cases with appendicitis, 358 (0.2%) of which had a concurrent diagnosis of C. diff.

The researchers found the proportion of cases with CDI in perforated appendicitis was greater than in the non-perforated cases (0.39% vs. 0.06%; p < .01).

More Analysis

After conducting a multivariate analysis, the team found perforated appendicitis (OR, 5.22) and anemia (OR, 4.95) were independent predictors of C. diff infections (P <0.001).

Next, the investigators adjusted for perforated appendicitis and found CDI cases had 4.78 days longer length of stay, as well as higher total charges of $29,887 (all P <0.0001) compared to non-C. diff cases.

“C. difficile infection is a rare, but impactful complication of pediatric appendicitis and is associated with greater disease severity,” the authors wrote. “Proper antibiotic stewardship could minimize the risk of C. difficile in pediatric appendicitis.”

C Diff After Surgery

Recently, researchers found perioperative hyperlactatemia and decreased lactate clearance among cardiac surgery patients may be predictors for occurrence of C diff infection post-surgery.

Investigators from Poland analyzed 12,235 cardiac surgery patients in order to determine if perioperative acid-base abnormalities, such as lactate disturbances, were able to predict the probability of incidence of C diff infection in these patients.

They noted that C diff is the third-most common major infection following cardiac surgery, but it is unclear whether these disturbances during the perioperative period influence C diff infection. The patients were treated between January 2014 and December 2019 and the most common procedures were heart valve surgery and coronary artery bypass grafting.

Beyond the usual, well-established risk factors, such as immune status, comorbidities, antibiotic exposure, exposure to spores and hospitalizations, the study authors wanted to determine the effects of hyperlactatemia and other acid-base disturbances.

Elevated lactate levels, for example, can be a marker of circulatory failure, tissue hypoxia, and intestinal ischemia.

Hyperlactatemia, when developed during surgery or within the first 6 hours post-operatively, is associated with increased risk for worse outcomes, including longer hospital stay and death.

Overall, 143 patients (1.2%) developed C diff infection.

During the procedure, after 4 hours, and after 12 hours, severe hyperlactatemia was more common in the C diff patients compared to controls. These patients also had higher glucose concentration than non-C diff patients during the procedure, immediately, and 4 hours post-operation. After 4 hours post-surgery, C diff patients also had more stress hyperglycemia, the authors noted.

The study, “Impact of Clostridium difficile infection on pediatric appendicitis,” was published online in Pediatric Surgery International.