ICU Stays Increase Risk of Clostridium difficile Infection

A longer ICU stay, recipients of piperacillin/tazobactam and having COPD were positively associated with C. difficile in trauma/surgery patients compared with medical patients.

Richard Watkins, MD, MS

The longer a trauma or surgery patient stays in the intensive care unit (ICU), the greater the risk for developing Clostridium difficile (C. difficile) infection, according to a new study.

Researchers from the Cleveland Clinic Akron General examined the data of 194 patients with C. difficile infection to examine the rates of the infection within the ICU. There were 25 trauma patients, 13 surgical patients, and the remaining 156 patients were classified as “medical patients"—aged 18 years or older. Because of the small number of trauma and surgical patients, they were grouped together for the purpose of the study.

The researchers sought to understand the differences in outcomes between the trauma and surgery patients compared to the medical patients, including variables such as hospital length of stay, ICU length of stay, days on a ventilator, number of days on vasopressors and survival. Secondly, the team also wanted to explore how previously prescribed antibiotics differed between the groups in their development of C. difficile infection.

The researchers collected data from patients based on their electronic medical records: general demographic data, white blood count, previously prescribed antibiotics before C. difficile diagnoses, and comorbidites, such as diabetes, malignant disease, smoking, heart disease, hypertension, chronic obstructive pulmonary disease (COPD) and more.

The C. difficile diagnoses were confirmed after evaluation of clinical and laboratory data. Patients were treated for fever, abdominal pain, and if they had 3 or more watery stools per day, an elevated white blood count, and a positive stool assay for C. difficile.

Researchers learned that most of the patients received at least 1 antibiotic prior to their C. difficile infection—79% of both groups. There were a higher percentage of patients in the trauma and surgery group who received piperacillin/ tazobactam before their C. difficile diagnoses compared to the medical patients (58% versus 37%). There were no differences between the 2 groups regarding profloxacin, ceftriaxone, cefepime or ampicillin/ sulbactam prescriptions, according to the report.

The number of days antibiotics were received before the development of C. difficile infection was higher in the trauma and surgery group compared to the medical group. Additionally, researchers said the time from admission into the ICU to receipt of the first dose of antibiotic was significantly less than the medical group compared to the trauma and surgery patients.

“For every one-day increase in the ICU length of stay, the odds of being in the trauma and surgical ICU were 30% higher than the odds of being in the medical group,” the researchers continued.

Having COPD was also positively associated with being in the trauma and surgery group, though admission from a nursing home, having diabetes, or being on vasopressors were negatively linked to being in the trauma and surgery group.

Patients who received piperacillin or tazobactam prior to their infection were 3.3 times more likely to have been in the trauma and surgery group, the researchers added, compared to patients who did not get those antibiotics.

“We were surprised to find that the longer a surgery or trauma patient stays in the ICU, the greater the risk for developing C. difficile infection,” study author Richard Watkins, MD, MS, Division of Infectious Diseases, Cleveland Clinic Akron General, told MD Magazine. “Physicians need to be aware of this association and get their patients out of the ICU as soon as possible.”

The paper, titled “Clostridium difficile Infection in Trauma, Surgery, and Medical Patients Admitted to the Intensive Care Unit” was published in the journal Surgical Infections.