Antibiotic prophylaxis and risk of Clostridium difficile infection after coronary artery bypass graft surgery

Abstract

Objective Antibiotic use, particularly type and duration, is a crucial modifiable risk factor for Clostridium difficile. Cardiac surgery is of particular interest because prophylactic antibiotics are recommended for 48 hours or less (vs ≤24 hours for noncardiac surgery), with increasing vancomycin use. We aimed to study associations between antibiotic prophylaxis (duration/vancomycin use) and C difficile among patients undergoing coronary artery bypass grafting. Methods We extracted data on coronary artery bypass grafting procedures from the national Premier Perspective claims database (2006–2013, n = 154,200, 233 hospitals). Multilevel multivariable logistic regressions measured associations between (1) duration (<2 days, “standard” vs ≥2 days, “extended”) and (2) type of antibiotic used (“cephalosporin,” “cephalosporin + vancomycin,” “vancomycin”) and C difficile as outcome. Results Overall C difficile prevalence was 0.21% (n = 329). Most patients (59.7%) received a cephalosporin only; in 33.1% vancomycin was added, whereas 7.2% received vancomycin only. Extended prophylaxis was used in 20.9%. In adjusted analyses, extended prophylaxis (vs standard) was associated with significantly increased C difficile risk (odds ratio, 1.43; confidence interval, 1.07–1.92), whereas no significant associations existed for vancomycin use as adjuvant or primary prophylactic compared with the use of cephalosporins (odds ratio, 1.21; confidence interval, 0.92–1.60, and odds ratio, 1.39; confidence interval, 0.94–2.05, respectively). Substantial inter-hospital variation exists in the percentage of extended antibiotic prophylaxis (interquartile range, 2.5–35.7), use of adjuvant vancomycin (interquartile range, 4.2–61.1), and vancomycin alone (interquartile range, 2.3–10.4). Conclusions Although extended use of antibiotic prophylaxis was associated with increased C difficile risk after coronary artery bypass grafting, vancomycin use was not. The observed hospital variation in antibiotic prophylaxis practices suggests great potential for efforts aimed at standardizing practices that subsequently could reduce C difficile risk.

Risk of surgical site infection, acute kidney injury, and Clostridium difficile infection following antibiotic prophylaxis with vancomycin plus a beta-lactam versus either drug alone: A national propensity-score-adjusted retrospective cohort study

“…Although unmeasured confounding and exposure to other nephrotoxins not accounted for in our analysis may partially explain these results, the findings are consistent with previous studies demonstrating an increase in AKI among patients receiving combination prophylaxis [10]. We found no increased risk of CDI in patients who received combination prophylaxis compared to a single agent, supporting other studies that have evaluated this question [25,26]. …”

Hygienemaßnahmen bei Clostridioides difficile-Infektion (CDI)

“…Dies gilt sowohl für Erwachsene [17,207], als auch für Kinder [109,208]. Selbst die perioperative Antibiotikaprophylaxe kann eine CDI auslösen, insbesondere wenn sie entgegen der Leitlinienvorgaben über mehr als 24 Stunden verabreicht wird [209,210]. Zur Behandlung der CDI wird das Absetzen der laufenden antibiotischen Therapie, soweit klinisch vertretbar, empfohlen [96,211].…”

Prevalence and Predictors of Postdischarge Antibiotic Use Following Mastectomy

“…The use of unnecessary antibiotics may result in additional costs and adverse events, in addition to selection of antibiotic-resistant bacteria 8 and Clostridium difficile infection. 9 …”