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

Abstract

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.

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

“…Clostridium difficile infection is an uncommon complication after stoma reversal surgery that occurs, according to this systematic review, approximately in 2.1% of the patients. Stoma closure surgery is an abdominal procedure with a relatively high incidence rate of CDI, ranging between 1.6 and 8.7% [5][6][7][8][9][10][11][12][13][14][15]. Although it is not a frequent complication, CDI is a potentially life-threatening complication, and it prolongs the costs and length of hospitalization.…”

“…Out of a total of 1263 papers screened, 11 (10 retrospective cohort studies and 1 randomized controlled trial [5][6][7][8][9][10][11][12][13][14][15]) met the inclusion criteria and were analysed (Fig. 1), including a previous paper from our group [5].…”

“…Table 1 shows the eleven papers analysed, including 17,857 patients who underwent stoma reversal surgery (both ileostomy and colostomy reversal were considered for inclusion); the overall incidence of CDI was 2.1% (381/17,857) [5][6][7][8][9][10][11][12][13][14][15].…”

“…There was one RCT [7] and ten non-randomized retrospective cohort studies [5,6,[8][9][10][11][12][13][14][15]. All non-randomized studies scored 7 or more on the Newcastle-Ottawa scale, and the RCTs had a low risk of bias according to Robin 2.0.…”

“…Colorectal surgery has been identified as a risk factor for Clostridium difficile infection (CDI) [1][2][3], although its occurrence is relatively rare, since as it has been reported in only 1.5% of patients [4]. However, stoma closure surgery has the highest incidence rate of CDI among abdominal procedures, ranging from 1.6 to 8.7% of cases [5][6][7][8][9][10][11][12][13][14][15].…”