Impact of Clostridium difficile colitis following closure of a diverting loop ileostomy: results of a matched cohort study

Clostridium difficile infection after stoma reversal surgery: a systematic review and meta-analysis of the literature

BACKGROUND

Clostridium difficile infection (CDI) has been described in the early post-operative phase after stoma reversal. This systematic review aimed to describe the incidence of CDI after stoma reversal and to identify pre-operative variables correlated with an increased risk of infection.

METHODS

A systematic review of the literature was conducted according to the PRISMA guidelines in March 2024. Manuscripts were included if reported at least one patient with CDI-associated diarrhoea following stoma reversal (colostomy/ileostomy). The primary outcome of interest was the incidence of CDI; the secondary outcome was the comparison of clinical variables (age, sex, time to stoma reversal, neo-adjuvant and adjuvant therapies after index colorectal procedure) in CDI-positive versus CDI-negative patients. A meta-analysis was performed when at least three studies reported on those variables.

RESULTS

Out of 43 eligible manuscripts, 1 randomized controlled trial and 10 retrospective studies were selected, including 17,857 patients (2.1% CDI). Overall, the mean age was 64.3 ± 11.6 years in the CDI group and 61.5 ± 12.6 years in the CDI-negative group (p = 0.51), with no significant difference in sex (p = 0.34). Univariable analyses documented that the mean time to stoma reversal was 53.9 ± 19.1 weeks in CDI patients and 39.8 ± 15.0 weeks in CDI-negative patients (p = 0.40) and a correlation between neo-adjuvant and adjuvant treatments with CDI (p < 0.001). A meta-analysis was performed for time to stoma reversal, age, sex, and neo-adjuvant therapies disclosing no significant differences for CDI (stoma delay, MD 11.59; 95%CI  24.32-1.13; age, MD 0.97; 95%CI 2.08-4.03; sex, OR1.11; 95%CI 0.88-1.41; neo-adjuvant, OR0.81; 95%CI 0.49-1.35). Meta-analysis including patients who underwent adjuvant therapy evidenced a higher risk of CDI (OR 2.88; 95%CI 1.01-8.17, p = 0.11).

CONCLUSION

CDI occurs in approximately 2.1% of patients after stoma reversal. Although a trend of increased delay in stoma reversal and a correlation with chemotherapy were documented in CDI patients, the use of adjuvant therapy was the only possible risk factor documented on meta-analysis.

PROSPERO REGISTRATION NUMBER

CRD42023484704.

Single-Centre Retrospective Audit of Clostridium difficile Infections Post Ileostomy Reversal

Background Clostridium difficile (C. difficile) infection can have serious implications on patient outcomes, especially post ileostomy reversal. The symptoms can range from asymptomatic/mild to severe, with significant morbidity or mortality. Thus far, no study has been published to determine the role and impact of preoperative C. difficile testing prior to ileostomy reversal. The aim of this audit was to identify risk factors for the development of post-ileostomy reversal C. difficile infection and provide further improvements and direction for future research. Methods All patients undergoing ileostomy reversal at the General Surgery Department at Sir Charles Gairdner Hospital, a tertiary centre in Perth, Western Australia, were retrospectively identified between January 2019 and June 2021. Demographics and key data points, such as specific types of antibiotic usage, were extracted from patient notes and analysed using IBM SPSS Statistics for Windows, version 27 (released 2020; IBM Corp., Armonk, New York, United States). Results Sixty-nine patients were identified in the audit period, with 8.70% of patients testing positive for C. difficile infection post ileostomy reversal. At the index ileostomy formation operation, postoperative use of quinolone antibiotics was statistically associated with an increased risk of developing C. difficile on ileostomy reversal (odds ratio (OR) = 15.25, confidence interval (CI) 95%, p = 0.035). Intraoperative nitroimidazole use was statistically associated with a reduced risk of C. difficile infection on ileostomy reversal (OR = 0.16, CI 95%, p = 0.045). Patients who had diverticulitis as their underlying disease pathology were 10 times more likely to develop C. difficile infection post ileostomy reversal, although this finding was not statistically significant in our study. Conclusion Several risk factors were identified, such as the use of quinolone antibiotics or having underlying diverticulitis as causes for ileostomy formation. The results from this audit provides further direction in designing further research studies into the role and impact of C. difficile testing and treatment in the perioperative period around ileostomy reversal.

Economic Impact of Recurrent Clostridioides difficile Infection in the USA: A Systematic Literature Review and Cost Synthesis

INTRODUCTION

Up to 35% of patients with a first episode of Clostridioides difficile infection (CDI) develop recurrent CDI (rCDI), and of those, up to 65% experience multiple recurrences. A systematic literature review (SLR) was conducted to review and summarize the economic impact of rCDI in the United States of America.

METHODS

English-language publications reporting real-world healthcare resource utilization (HRU) and/or direct medical costs associated with rCDI in the USA were searched in MEDLINE, MEDLINE In-Process, Embase, and the Cochrane Library databases over the past 10 years (2012-2022), as well as in selected scientific conferences that publish research on rCDI and its economic burden over the past 3 years (2019-2022). HRU and costs identified through the SLR were synthesized to estimate annual rCDI-attributable direct medical costs to inform the economic impact of rCDI from a US third-party payer's perspective.

RESULTS

A total of 661 publications were retrieved, and 31 of them met all selection criteria. Substantial variability was found across these publications in terms of data source, patient population, sample size, definition of rCDI, follow-up period, outcomes reported, analytic approach, and methods to adjudicate rCDI-attributable costs. Only one study reported rCDI-attributable costs over 12 months. Synthesizing across the relevant publications using a component-based cost approach, the per-patient per-year rCDI-attributable direct medical cost was estimated to range from $67,837 to $82,268.

CONCLUSIONS

While real-world studies on economic impact of rCDI in the USA suggested a high-cost burden, inconsistency in methodologies and results reporting warranted a component-based cost synthesis approach to estimate the annual medical cost burden of rCDI. Utilizing available literature, we estimated the average annual rCDI-attributable medical costs to allow for consistent economic assessments of rCDI and identify the budget impact on US payers.

Cost-Effectiveness Analysis of REBYOTA™ (Fecal Microbiota, Live-jslm [FMBL]) Versus Standard of Care for the Prevention of Recurrent Clostridioides difficile Infection in the USA

INTRODUCTION

Recurrent Clostridioides difficile infection (rCDI) is common and associated with considerable clinical and economic consequences. REBYOTA™ (fecal microbiota, live-jslm [FMBL]) is a microbiota-based live biotherapeutic approved for the prevention of rCDI following antibiotic treatment for rCDI. We sought to evaluate cost-effectiveness of FMBL compared to standard of care (SOC) from a US third-party payer perspective among patients with one or more (≥ 1) recurrences.

METHODS

A Markov model with a lifetime time horizon was developed. The model population included adult patients who had ≥ 1 recurrence after a primary CDI episode and had completed ≥ 1 round of antibiotics, or had ≥ 2 severe CDI episodes resulting in hospitalization within the last year. The model consisted of six health states with an 8-week model cycle: rCDI, absence of CDI after recurrence, colectomy, ileostomy, ileostomy reversal, and death. Drug costs and rCDI-related medical costs were estimated in 2022 US dollars and discounted at 3% annually. Deterministic sensitivity analyses were performed.

RESULTS

Compared to SOC, FMBL at $9000/course resulted in an incremental cost-effectiveness ratio (ICER) of $18,727 per quality-adjusted life year (QALY) gained. The incremental cost was $5336 (FMBL $79,236, SOC $73,900) and the incremental effectiveness was 0.285 QALYs (FMBL 10.346, SOC 10.061). The cumulative drug acquisition and administration costs for the FMBL and SOC arms were $24,245 and $16,876, while rCDI-related medical costs for FMBL and SOC were $54,991 and $57,024, respectively. The ICER in the subgroup of patients at first recurrence was $13,727 per QALY gained. FMBL remained cost-effective across all sensitivity analyses.

CONCLUSIONS

FMBL was found to be cost-effective compared to SOC for the prevention of rCDI with more benefits among patients at first recurrence, with an ICER far below the payer ICER threshold of $100,000. Patients treated with FMBL experienced higher total QALYs and reduced healthcare resource utilization, including reduced hospitalizations.

Budget Impact Analysis of REBYOTA™ (Fecal Microbiota, Live-jslm [FMBL]) for Preventing Recurrent Clostridioides difficile Infection in the US

INTRODUCTION

Patients with Clostridioides difficile infection (CDI) often experience recurrences (rCDI), which are associated with high morbidity, mortality, and healthcare expenditures. REBYOTA™ (fecal microbiota, live-jslm [FMBL]) is a microbiota-based live biotherapeutic approved for the prevention of rCDI following antibiotic treatment for rCDI. We quantified the budget impact of FMBL during the first 3 years following introduction from a third-party US payer perspective.

METHODS

A decision-tree model was used to estimate the budget impact of one-course FMBL by comparing costs under the scenario with FMBL to the scenario without FMBL (standard of care) in patients with one or more (≥ 1) recurrences after a primary episode of CDI and had completed ≥ 1 round of antibiotic treatments. Drug costs, rCDI-related medical costs, and budget impact over 1-3 years were estimated in 2022 US dollars. One-way sensitivity analyses were performed.

RESULTS

For an insurance plan with a population size of 1,000,000, 468 patients per year were estimated to have ≥ 1 rCDI. The budget impact of one-course FMBL at $9000/course was cost-saving at an» average of -$0.0039 on a per-member-per-month (PMPM) basis, an average of -$8.30 on a per-treated-member-per-month (PTMPM) basis, and a total of -$139,865 on a plan level assuming 5%, 15%, and 20% of patients receive FMBL over 1-3 years, respectively. The scenario with FMBL entry was associated with higher drug costs (difference at $0.0474 PMPM; $101.26 PTMPM; $1,706,445 total plan) and lower rCDI-related medical costs (difference at -$0.0513 PMPM; -$109.56 PTMPM; -$1,846,309 total plan). The budget impact of FMBL in patients at first rCDI was cost-saving at -$0.0139 PMPM, -$84.78 PTMPM, corresponding to an annual savings of $500,022.

CONCLUSIONS

FMBL has a cost-saving budget impact for a US payer, with higher initial drug costs being offset by savings in rCDI-related medical costs. Greater cost saving was found in patients at first recurrence.

OUP accepted manuscript

Background

Diverting ileostomy during resection of rectal cancer is frequently performed in patients at risk of anastomotic failure. Clostridium difficile infection (CDI) is reported to be frequent in patients who receive ileostomy closure with a questionable association to postoperative anastomosis leak. The primary aim of this study was to determine the incidence of CDI following ileostomy closure in patients who underwent rectal cancer surgery; the secondary aim was to assess the rate of postileostomy closure CDI in patients who presented with leakage at the original colorectal anastomosis site.

Methods

Medical records of patients with rectal cancer who underwent ileostomy closure between January 2015 and December 2019 were retrospectively reviewed. All patients had previously received resection and anastomosis for primary rectal cancer with diverting ileostomy. Data regarding CDI incidence, preoperative status, perioperative management, and clinical outcomes were collected. CDI positivity was determined by direct real-time PCR and enzyme-linked fluorescent assays for detecting toxin A and B.Statistical analyses were computed for CDI risk factors.

Results

A total of 1270 patients were included and 208 patients were tested for CDI owing to colitis-related symptoms. The incidence of CDI was 3.6 per cent (46 patients). Multivariable analysis for CDI risk factors identified adjuvant chemotherapy (hazard ratio (HR) 2.28; P = 0.034) and colorectal anastomosis leakage prior to CDI (HR 3.75; P = 0.008). Finally, patients with CDI showed higher colorectal anastomosis leakage risk in multivariable analysis after ileostomy closure (HR 6.922; P = 0.001).

Conclusion

Patients with CDI presented with a significantly higher rate of colorectal anastomosis leakage prior to ileostomy closure.

Delayed ileostomy closure increases the odds of Clostridium difficile infection

AIM

A diverting ileostomy is typically performed to divert intestinal contents in high-risk colorectal anastomoses. Ileostomy closure is associated with high rates of postoperative Clostridium difficile infection (CDI). Risk factors for the development of CDI are unclear; however, a correlation has been observed with delayed closure. This study aimed to assess the odds of developing CDI in patients who had a delay to reversal of ileostomy, compared to those who had no delay.

METHODS

A retrospective cohort study was conducted of patients undergoing reversal of ileostomy between 2010 and 2019 at a single tertiary centre. A delay to reversal of ileostomy was defined if the procedure was performed at >365 days following the index procedure. CDI was defined as the presence of Clostridium difficile toxin associated with diarrhoea. Univariable logistic regression analysis was performed to estimate odds of CDI for each covariable, comparing patients who had a delay to reversal of ileostomy with those who did not. Multivariable logistic regression analysis was used to adjust for the potential confounding effects of covariables.

RESULTS

Of 195 patients, 11 (5.6%), developed postoperative CDI. Multivariable analysis showed that delay to reversal of ileostomy was associated with a nearly 7-fold increase in odds of CDI (OR = 6.95, CI: 1.06-81.6; p-value = 0.03).

CONCLUSION

A delay to reversal of ileostomy of >365 days was associated with a higher incidence of CDI postoperatively. Careful consideration should be given to the timing of reversal and appropriate preoperative counselling of patients.

Expanding an Economic Evaluation of the Veterans Affairs (VA) Methicillin-resistant Staphylococcus aureus (MRSA) Prevention Initiative to Include Prevention of Infections From Other Pathogens

BACKGROUND

In October 2007, Veterans Affairs (VA) launched a nationwide effort to reduce methicillin-resistant Staphylococcus aureus (MRSA) transmission called the National MRSA Prevention Initiative. Although the initiative focused on MRSA, recent evidence suggests that it also led to a significant decrease in hospital-onset (HO) gram-negative rod (GNR) bacteremia, vancomycin-resistant Enterococci (VRE), and Clostridioides difficile infections. The objective of this analysis was to evaluate the cost-effectiveness and the budget impact of the initiative taking into account MRSA, GNR, VRE, and C. difficile infections.

METHODS

We developed an economic model using published data on the rate of MRSA hospital-acquired infections (HAIs) and HO-GNR bacteremia in the VA from October 2007 to September 2015, estimates of the attributable cost and mortality of these infections, and the costs associated with the intervention obtained through a microcosting approach. We explored several different assumptions for the rate of infections that would have occurred if the initiative had not been implemented. Effectiveness was measured in life-years (LYs) gained.

RESULTS

We found that during fiscal years 2008-2015, the initiative resulted in an estimated 4761-9236 fewer MRSA HAIs, 1447-2159 fewer HO-GNR bacteremia, 3083-3602 fewer C. difficile infections, and 2075-5393 fewer VRE infections. The initiative itself was estimated to cost $561 million over this 8-year period, whereas the cost savings from prevented MRSA HAIs ranged from $165 to $315 million and from prevented HO-GNR bacteremia, CRE and C. difficile infections ranged from $174 to $200 million. The incremental cost-effectiveness of the initiative ranged from $12 146 to $38 673/LY when just including MRSA HAIs and from $1354 to $4369/LY when including the additional pathogens. The overall impact on the VA's budget ranged from $67 to$195 million.

CONCLUSIONS

An MRSA surveillance and prevention strategy in VA may have prevented a substantial number of infections from MRSA and other organisms. The net increase in cost from implementing this strategy was quite small when considering infections from all types of organisms. Including spillover effects of organism-specific prevention efforts onto other organisms can provide a more comprehensive evaluation of the costs and benefits of these interventions.

The gut microbiota and colorectal surgery outcomes: facts or hype? A narrative review

BACKGROUND

The gut microbiota (GM) has been proposed as one of the main determinants of colorectal surgery complications and theorized as the "missing factor" that could explain still poorly understood complications. Herein, we investigate this theory and report the current evidence on the role of the GM in colorectal surgery.

METHODS

We first present the findings associating the role of the GM with the physiological response to surgery. Second, the change in GM composition during and after surgery and its association with colorectal surgery complications (ileus, adhesions, surgical-site infections, anastomotic leak, and diversion colitis) are reviewed. Finally, we present the findings linking GM science to the application of the enhanced recovery after surgery (ERAS) protocol, for the use of oral antibiotics with mechanical bowel preparation and for the administration of probiotics/synbiotics.

RESULTS

According to preclinical and translational evidence, the GM is capable of influencing colorectal surgery outcomes. Clinical evidence supports the application of an ERAS protocol and the preoperative administration of multistrain probiotics/synbiotics. GM manipulation with oral antibiotics with mechanical bowel preparation still has uncertain benefits in right-sided colic resection but is very promising for left-sided colic resection.

CONCLUSIONS

The GM may be a determinant of colorectal surgery outcomes. There is an emerging need to implement translational research on the topic. Future clinical studies should clarify the composition of preoperative and postoperative GM and the impact of the GM on different colorectal surgery complications and should assess the validity of GM-targeted measures in effectively reducing complications for all colorectal surgery locations.

A history of Clostridioides difficile infection portends infection recurrence and worse outcomes after stoma reversal

BACKGROUND

Clostridioides difficile infection is reported to occur after 2.2% of colorectal operations and is associated with longer length of hospital stay, greater overall healthcare cost, and significant morbidity and mortality. The incidence of Clostridioides difficile infection is greatest after elective stoma reversal. The purpose of this study was to evaluate the effect of prior Clostridioides difficile infection on patients undergoing stoma reversal. We hypothesized that patients with a history of Clostridioides difficile infection who underwent stoma reversal will be at an increased risk of postoperative Clostridioides difficile infection compared with patients without a history of Clostridioides difficile infection.

METHODS

This was an observational cohort study of patients undergoing elective stoma reversal surgery by colorectal surgeons at a single academic institution during a 10-year period. A prospectively maintained institutional database was queried to identify 454 patients who underwent stoma reversal surgery between January 1, 2007 and December 31, 2017. The primary outcomes were Clostridioides difficile infection after stoma reversal and time to Clostridioides difficile infection after bowel refunctionalization. Secondary outcomes included postoperative complications, length of hospital stay, discharge destination, and 30-day readmission rate. Univariate and multivariable logistic regression analyses were conducted to identify factors associated with Clostridioides difficile infection after stoma reversal.

RESULTS

A total of 445 patients were identified who underwent elective stoma reversal, 42 of whom had a history of Clostridioides difficile infection before the stoma reversal. There were no significant differences in patient age, number of days diverted, or use of perioperative antibiotics between patients with and without a history of Clostridioides difficile infection. The incidence of postreversal Clostridioides difficile infection was 23.4% in patients with a history of Clostridioides difficile infection compared with 9.6% in patients with no Clostridioides difficile infection history (P = .004); however, time to Clostridioides difficile infection after reversal did not differ. History of Clostridioides difficile infection was also associated with greater risk of postoperative complications (26.2% vs 9.4%, P < .01), increased length of stay (3 vs 5 days postoperatively, P < .01), increased likelihood of discharge to a skilled-care facility (11.9% vs 6.2%, P < .01), and readmission (13.7 vs 31.0%, P < .01) within 30 days. In a multivariable logistic regression model, history of Clostridioides difficile infection, increased length of hospital stay, and discharge to a skilled facility were associated with increased risk of Clostridioides difficile infection after reversal, while proton pump inhibitors use was associated with decreased risk of Clostridioides difficile infection.

CONCLUSION

Patients with a prior history of Clostridioides difficile infection who underwent stoma reversal exhibited higher rates of postoperative Clostridioides difficile infection and were at greater risk of postoperative complications, discharge to a skilled facility, and 30-day readmission. Furthermore, research into interventions aimed at improving outcomes in this unique, high-risk population is needed.

Elective Stoma Reversal Has a Higher Incidence of Postoperative Clostridium Difficile Infection Compared With Elective Colectomy: An Analysis Using the American College of Surgeons National Surgical Quality Improvement Program and Targeted Colectomy Databases

BACKGROUND

Clostridium difficile infection is caused by the proliferation of a gram-positive anaerobic bacteria after medical or surgical intervention and can result in toxic complications, emergent surgery, and death.

OBJECTIVE

This analysis evaluates the incidence of C difficile infection in elective restoration of intestinal continuity compared with elective colon resection.

DESIGN

This was a retrospective database review of the 2015 American College of Surgeons National Surgical Quality Improvement Project and targeted colectomy database.

SETTINGS

The intervention cohort was defined as the primary Current Procedural Terminology codes for ileostomy/colostomy reversal (44227, 44620, 44625, and 44626) and International Classification of Diseases codes for ileostomy/colostomy status (VV44.2, VV44.3, VV55.2, VV55.3, Z93.2, Z93.3, Z43.3, and Z43.2).

PATIENTS

A total of 2235 patients underwent elective stoma reversal compared with 10403 patients who underwent elective colon resection.

INTERVENTION

Multivariate regression modeling of the impact of stoma reversal on postoperative C difficile infection risk was used as the study intervention.

MAIN OUTCOME MEASURES

The incidence of C difficile infection in the 30 days after surgery was measured.

RESULTS

The incidence of C difficile infection in the 30-day postoperative period was significantly higher (3.04% vs 1.25%; p < 0.001) in patients undergoing stoma reversal. After controlling for differences in cohorts, regression analysis suggested that stoma reversal (OR = 2.701 (95% CI, 1.966-3.711); p < 0.001), smoking (OR = 1.520 (95% CI, 1.063-2.174); p = 0.022), steroids (OR = 1.677 (95% CI, 1.005-2.779); p = 0.048), and disseminated cancer (OR = 2.312 (95% CI, 1.437-3.719); p = 0.001) were associated with C difficile infection incidence in the 30-day postoperative period.

LIMITATIONS

The study was limited because it was a retrospective database review with observational bias.

CONCLUSIONS

Patients who undergo elective stoma reversal have a higher incidence of postoperative C difficile infection compared with patients who undergo an elective colectomy. Given the impact of postoperative C difficile infection, a heightened sense of suspicion should be given to symptomatic patients after stoma reversal. See at Video Abstract at http://links.lww.com/DCR/A553.

A systematic review of Clostridium difficile infection following reversal of ileostomy

AIM

The incidence of Clostridium difficile infection (CDI) has been reported to be as high as 4% following ileostomy reversal. CDI can be associated with significant morbidity. A systematic review on this subject has not been previously reported; our aim was to review the literature to establish incidence and to evaluate the factors that may contribute to an increased risk of CDI following ileostomy reversal.

METHOD

A systematic review of Ovid, Embase and Medline was undertaken. Search terms included C. difficile, reversal of ileostomy and ileostomy closure. Articles were included where at least one case of C. difficile-associated diarrhoea following reversal of defunctioning ileostomy was reported. Data extraction for articles was performed by two authors, using predefined data fields. The primary outcome measure was incidence of CDI amongst patients undergoing ileostomy reversal. Secondary outcomes were defunctioning time, antibiotic regime, acid suppression, time to onset of symptoms and study conclusions including colectomy and mortality rate.

RESULTS

Eleven articles were included (five case reports and six cohort studies). The overall incidence of CDI was 1.8% (242/13 728). The mean defunctioning time was 8.7 months (range 6-12). A variety of antibiotic regimes were described. Mean time to onset of symptoms was 6 days (range 3-14). Use of acid suppression, colectomy or mortality rate were frequently not reported.

CONCLUSION

CDI should be recognized as a potentially life-threatening complication of ileostomy closure. Careful consideration should be given to peri-operative antibiotic regime, acid suppression, timing of reversal and appropriate preoperative counselling of patients.

Risk Factors that Predict Recurrent Clostridium difficile Infections in Surgical Patients

Clostridium difficile (C. difficile) infection (CDI) is a serious problem mostly studied during patients’ index infections. The aim of this study is to define the incidence of primary and recurrent postoperative (postop) CDI in a single institution's entire surgical population and to identify risk factors that influence disease recurrence. Using electronic medical records from 2002 to 2012, charts were reviewed from all patients with laboratory-proven (enzyme-linked immunosorbent assay or polymerase chain reaction methods) C. difficile-positive stool samples. Index postop CDI was defined as a positive C. difficile assay (CDA) within 30 days of surgery and recurrence was defined as a positive CDA within 30 days of any surgery in a patient with a previously documented positive CDA. Patient demographics, surgical diagnoses, and laboratory data were recorded. Approximately 342,000 surgeries were performed in the study period with a 0.6 per cent (2188 patients) incidence of index postop CDI. Patients undergoing musculoskeletal surgery had the highest recurrent CDI rate [odds ratio (OR) 3.09 (1.47–6.49), P = 0.003]. Use of any steroid (OR 2.45 [1.43–4.20], P = 0.002) or other immunosuppressant (OR 2.64 [1.09–6.38], P = 0.011) within six months of surgery was associated with an increased risk of the development of a recurrent CDI. Across surgical specialties at our institution, postop index CDI is low and patients have about a 5-fold increased risk for developing recurrent CDI. Patients undergoing musculoskeletal surgery are at greater risk for CDI recurrence and younger age, use of steroids and immune modulators, and surgery by organ system are independent risk factors for a recurrent CDI.

Cost of hospital management of Clostridium difficile infection in United States-a meta-analysis and modelling study

Background

Clostridium difficile infection (CDI) is the leading cause of infectious nosocomial diarrhoea but the economic costs of CDI on healthcare systems in the US remain uncertain.

Methods

We conducted a systematic search for published studies investigating the direct medical cost associated with CDI hospital management in the past 10 years (2005–2015) and included 42 studies to the final data analysis to estimate the financial impact of CDI in the US. We also conducted a meta-analysis of all costs using Monte Carlo simulation.

Results

The average cost for CDI case management and average CDI-attributable costs per case were $42,316 (90 % CI: $39,886, $44,765) and $21,448 (90 % CI: $21,152, $21,744) in 2015 US dollars. Hospital-onset CDI-attributable cost per case was $34,157 (90 % CI: $33,134, $35,180), which was 1.5 times the cost of community-onset CDI ($20,095 [90 % CI: $4991, $35,204]). The average and incremental length of stay (LOS) for CDI inpatient treatment were 11.1 (90 % CI: 8.7–13.6) and 9.7 (90 % CI: 9.6–9.8) days respectively. Total annual CDI-attributable cost in the US is estimated US$6.3 (Range: $1.9–$7.0) billion. Total annual CDI hospital management required nearly 2.4 million days of inpatient stay.

Conclusions

This review indicates that CDI places a significant financial burden on the US healthcare system. This review adds strong evidence to aid policy-making on adequate resource allocation to CDI prevention and treatment in the US. Future studies should focus on recurrent CDI, CDI in long-term care facilities and persons with comorbidities and indirect cost from a societal perspective. Health-economic studies for CDI preventive intervention are needed.

Electronic supplementary material

The online version of this article (doi:10.1186/s12879-016-1786-6) contains supplementary material, which is available to authorized users.

Cryptogenic repetitive severe colitis after ileostomy closure

We describe a case of cryptogenic repetitive severe colitis after ileostomy closure. A 50-year-old man was referred to our hospital for treatment of advanced rectal cancer. The patient underwent laparoscopic intersphincteric resection combined with synchronous partial liver resection for colorectal liver metastasis detected intraoperatively and construction of a diverting ileostomy. Ileostomy closure was performed 3 months later. Five days following ileostomy closure, the patient complained of lower abdominal pain and developed multiple daily fever episodes. Colonoscopy revealed multiple ulcers in the sigmoid colon and rectum. Because symptoms did not improve despite fasting and antibiotic therapy, ileostomy reconstruction was performed. Re-closure was performed 6 months after the previous ileostomy closure; however, severe colitis recurred with similar symptoms, and construction of a colostomy at the transverse colon was then performed. Despite varied examinations, the cause of the colitis was not identified. To our knowledge, there are no previous reports of repetitive severe colitis after ileostomy closure.

Clostridium difficile infection after ileostomy closure mimicking anastomotic leak

Clostridium difficile infection is linked to antibiotic exposure, with elderly and immunocompromised hospitalised patients being particularly at risk. The symptoms range from mild diarrhoea to life-threatening fulminant colitis. We describe an unusual presentation of C. difficile infection after closure of ileostomy in a healthy 60-year-old man with a history of low anterior resection and defunctioning ileostomy for rectal tumour. On the third day postoperatively, the patient developed left lower abdominal pain and profuse diarrhoea. With worsening symptoms and steadily increasing inflammatory markers over the following few days, concerns were raised about an anastomotic leak with pelvic abscess. CT of the abdomen/pelvis on day 7 surprisingly showed colitis in the neorectum/sigmoid colon. A stool test confirmed C. difficile infection.

Postoperative diarrhea and high ostomy output impact postoperative outcomes after elective colon and rectal operations regardless of Clostridium difficile infection

BACKGROUND

We aimed to review and compare outcomes of patients with and without Clostridium difficile infection (CDI) after elective colorectal operations.

METHODS

Retrospective cohort study of patients with CDI after elective colon and rectal operations from 2007 to 2012 (Group A) was conducted. Outcomes were compared with patients with a negative C. difficile toxin assay performed for postoperative diarrhea or high stoma output (Group B) and matched controls (Group C).

RESULTS

Forty-four patients (median age 53 years) developed CDI postoperatively (Group A). Fourteen patients (32%) had surgical site infections. Both Group A and Group B patients received ertapenem as preoperative antibiotic prophylaxis significantly more often than matched controls (P < .0001), and also had significantly more surgical site infections (P = .004), longer hospital stays (P = .003), and more readmissions (P = .02) compared with Group C patients.

CONCLUSIONS

In this study, postoperative CDI was uncommon, of low morbidity, and no mortality. Postoperative diarrhea and high stoma output, whether in patients who are C. difficile positive or not, appear to impact postoperative outcomes.

The economic impact of Clostridium difficile infection: a systematic review

OBJECTIVES

With Clostridium difficile infection (CDI) on the rise, knowledge of the current economic burden of CDI can inform decisions on interventions related to CDI. We systematically reviewed CDI cost-of-illness (COI) studies.

METHODS

We performed literature searches in six databases: MEDLINE, Embase, the Health Technology Assessment Database, the National Health Service Economic Evaluation Database, the Cost-Effectiveness Analysis Registry, and EconLit. We also searched gray literature and conducted reference list searches. Two reviewers screened articles independently. One reviewer abstracted data and assessed quality using a modified guideline for economic evaluations. The second reviewer validated the abstraction and assessment.

RESULTS

We identified 45 COI studies between 1988 and June 2014. Most (84%) of the studies were from the United States, calculating costs of hospital stays (87%), and focusing on direct costs (100%). Attributable mean CDI costs ranged from $8,911 to $30,049 for hospitalized patients. Few studies stated resource quantification methods (0%), an epidemiological approach (0%), or a justified study perspective (16%) in their cost analyses. In addition, few studies conducted sensitivity analyses (7%).

CONCLUSIONS

Forty-five COI studies quantified and confirmed the economic impact of CDI. Costing methods across studies were heterogeneous. Future studies should follow standard COI methodology, expand study perspectives (e.g., patient), and explore populations least studied (e.g., community-acquired CDI).

Increased postoperative complications after protective ileostomy closure delay: An institutional study

AIM: To study the morbidity and complications associated to ileostomy reversal in colorectal surgery patients, and if these are related to the time of closure.

METHODS: A retrospective analysis of 93 patients, who had undergone elective ileostomy closure between 2009 and 2013 was performed. Demographic, clinical and surgical variables were reviewed for analysis. All complications were recorded, and classified according to the Clavien-Dindo Classification. Statistical univariate and multivariate analysis was performed, setting a P value of 0.05 for significance.

RESULTS: The patients had a mean age of 60.3 years, 58% male. The main procedure for ileostomy creation was rectal cancer (56%), and 37% had received preoperative chemo-radiotherapy. The average delay from creation to closure of the ileostomy was 10.3 mo. Postoperative complications occurred in 40% of the patients, with 1% mortality. The most frequent were ileus (13%) and wound infection (13%). Pseudomembranous colitis appeared in 4%. Increased postoperative complications were associated with delay in ileostomy closure (P = 0.041). Male patients had more complications (P = 0.042), mainly wound infections (P = 0.007). Pseudomembranous colitis was also associated with the delay in ileostomy closure (P = 0.003). End-to-end intestinal anastomosis without resection was significantly associated with postoperative ileus (P = 0.037).

CONCLUSION: Although closure of a protective ileostomy is a fairly common surgical procedure, it has a high rate of complications, and this must be taken into account when the indication is made. The delay in stoma closure can increase the rate of complications in general, and specifically wound infections and colitis.