THAs Performed Within 6 Months of Clostridioides difficile Infection Are Associated with Increased Risk of 90-Day Complications

Abstract

Background Clostridioides difficile infection (CDI) may be a surrogate for poor patient health. As such, a history of CDI before THA may be used to identify patients at higher risk for postoperative CDI and complications after THA. Investigations into the associations between CDI before THA and postoperative CDI and complications are lacking. Questions/purposes We compared the (1) frequency and potential risk factors for CDI after THA, (2) the frequency of 90-day complications after THA in patients with and without a history of CDI, and (3) the length of stay and frequency of readmissions in patients experiencing CDIs more than 6 months before THA, patients experiencing CDIs in the 6 months before THA, and patients without a history of CDI. Methods Patients undergoing primary THA from 2010 to 2019 were identified in the PearlDiver database using ICD and Current Procedural Terminology codes (n = 714,185). This analysis included Medicare, Medicaid, and private insurance claims across the United States with the ability to perform longitudinal and costs analysis using large patient samples to improve generalizability and reduce error rates. Patients with a history of CDI before THA (n = 5196) were stratified into two groups: those with CDIs that occurred more than 6 months before THA (n = 4003, median 2.2 years [interquartile range 1.2 to 3.6]) and those experiencing CDIs within the 6 months before THA (n = 1193). These patients were compared with the remaining 708,989 patients without a history of CDI before THA. Multivariable logistic regression was used to evaluate the association of risk factors and incidence of 90-day postoperative CDI in patients with a history of CDI. Variables such as antibiotic use, proton pump inhibitor use, chemotherapy, and inflammatory bowel disease were included in the models. Chi-square and unadjusted odds ratios with 95% confidence intervals were used to compare complication frequencies. A Bonferroni correction adjusted the p value significance threshold to < 0.003. Results Prior CDI during either timespan was associated with higher unadjusted odds for postoperative CDI (CDI > 6 months before THA: OR 8.44 [95% CI 6.95 to 10.14]; p < 0.001; CDI ≤ 6 months before THA: OR 49.92 [95% CI 42.26 to 58.54]; p < 0.001). None of the risk factors included in the regression were associated with increased odds for postoperative CDI in patients with preoperative history of CDI. Patients with a history of CDI before THA were associated with higher unadjusted odds for every 90-day complication compared with patients without a history of CDI before THA. CDI during either timespan was associated with longer lengths of stay (no CDI before THA: 3.8 days; CDI > 6 months before THA: 4.5 days; CDI ≤ 6 months before THA: 5.3 days; p < 0.001) and 90-day readmissions (CDI > 6 months before THA: OR 2.21 [95% CI 1.98 to 2.47]; p < 0.001; CDI ≤ 6 months before THA: OR 3.39 [95% CI 2.85 to 4.02]; p < 0.001). Conclusion Having CDI before THA was associated with higher odds of postoperative CDI compared with patients without a history of CDI. A history of CDI within the 6 months before THA was associated with the greatest odds for postoperative complications and readmissions. Providers should strongly consider delaying THA until 6 months after CDI, if possible, to provide adequate time for patient recovery and eradication of infection. Level of Evidence Level III, therapeutic study.

C. Difficile Infection within 6 Months before TKA Is Associated with Increased Short-Term Complications

“…1,2 However, history of CDI is missing from these recommendations despite its strong associations with recurrence and poor outcomes following lower extremity arthro-plasty. [7][8][9] Furthermore, an improved understanding of whether CDI is a modifiable or nonmodifiable risk factor, given its high recurrence rate, is needed. 10 Additionally, a temporal relationship between CDI and subsequent operations has been reported but is limited to THA.…”

“…10 Additionally, a temporal relationship between CDI and subsequent operations has been reported but is limited to THA. 7 We sought to examine patients who were diagnosed with CDI more than and within 6 months prior to a TKA, as well as comparison to a control cohort of patients without history of CDI. Patients who developed CDI within 6 months prior to TKA were associated with the highest odds of encountering 90-day CDI, medical/surgical complications, as well as increased readmissions and prolonged lengths of stay.…”

CORR Insights®: THAs Performed Within 6 Months of Clostridioides difficile Infection Are Associated with Increased Risk of 90-day Complications

“…The authors found that after 6 months following C. difficile infection, the risk of complications following THA decreased, suggesting that the patient’s health improves after successful resolution of the C . difficile infection [2]. The findings from this study indicate that for patients with a history of C. difficile infection, surgeons should delay hip replacement for at least 6 months after treatment of the infection.…”

“…The current study by Douglas et al [2] identifies another important modifiable risk factor: duration of time after treatment of Clostridioides difficile infection. The occurrence of C .…”

“…Although Douglas et al [2] found that patients who had recovered from C . difficile infection after 6 months had a lower risk of complications than patients who had C .…”