Risk Factors for a Fulminant Clostridium Difficile Infection after Cardiac Surgery: A Retrospective Single-Center Analysis

Objectives: Clostridium difficile (CD) causes 10–20% of diarrheal diseases after surgical interventions. The clinical presentation ranges from mild diarrhea to severe courses with pseudomembranous colitis, toxic megacolon, sepsis, and multiorgan failure. The mortality increases rapidly in severe and complex cases. Preventive screening or prophylactic therapies are not useful. This study was therefore conducted to detect risk factors for a fulminant CD infection (CDI) in cardiac surgery patients.

Methods: Between April 1999 and April 2011 41466 patients underwent cardiac surgery at our center. The review of our hospital database revealed 1256 patients (3.0%) with postoperative diarrheal disease testing positive for CD. A fulminant CDI occurred in 153 patients (12.2%) and was defined as the incidence of gastrointestinal complications, e.g., pseudomembranous colitis, and/or the need for post-cardiac surgery laparotomy. Analysis of demographic, peri-operative and survival data was performed and predictors for a fulminant CDI were calculated by binary logistic regression analysis.

Results: The 30-day-mortality was 6.1% (n = 77) for the entire cohort with a significantly higher mortality for the patients with a fulminant CDI (21.6 vs. 4.0%, p > 0.001). Also, the overall-mortality (27.7%, n = 348) was higher for the patients with a fulminant course of the disease (21.6 vs. 4.0%, p>0.001) with a laparotomy required in 36.6% (n = 56) of the cases.

Independent predictors for a fulminant CDI were: diabetes mellitus type 2 (OR 1.79, CI 1.19–2.68, p = 0.005), preoperative ventilation (OR 4.13, CI 1.59–10.74, p = 0.004), more than 8 units of red blood cell concentrates (OR 2.15, CI 1.13–4.12, p = 0.020), and more than 5 units of fresh frozen plasma (OR 3.30, CI 2.03–5.37, p < 0.001).

Conclusion: Independent risk factors could be determined for the development of a fulminant CDI. Close monitoring of these endangered patients is important to establish an early onset of therapy and thus avoid fulminant courses of CDI after cardiac surgery.