P. D. Strassle1,3, J. Samples1, E. E. Sickbert-Bennet2,3, D. J. Weber2,3, T. S. Sadiq1, N. Chaumont1 1University Of North Carolina At Chapel Hill, School Of Medicine,Department Of Surgery,Chapel Hill, NC, USA 2University Of North Carolina At Chapel Hill, School Of Medicine,Department Of Medicine,Chapel Hill, NC, USA 3University Of North Carolina At Chapel Hill, Gillings School Of Global Public Health,Department Of Epidemiology,Chapel Hill, NC, USA
Introduction: In the last 10 years, recognition of Clostridium difficile infection (CDI) in patients with ileal pouch-anal anastomosis (IPAA) has been increasingly recognized. Despite the growing body of literature, conclusions about the incidence and risk factors of CDI in IPAA patients have been limited by single-institution studies, small sample sizes, and short follow-up. The goal of this study was to estimate the incidence and potential risk factors of CDI in patients with IPAA.
Methods: Patients diagnosed with ulcerative colitis, Crohn’s disease, or familial adenomatous polyposis, and undergoing an ileal pouch procedure between 2004 and 2013 in the Truven Health Analytics MarketScan® database were eligible for inclusion. Patients were required to have health insurance coverage for at least 6 months before and 30 days after surgery.
Kaplan-Meier survival curves were used to estimate the 2-year risk of infection. CDI was identified using ICD-9 CM code 008.45, which has 78.0% sensitivity and 99.7% specificity. Multivariable Cox proportional hazard regression was used to assess the effect of potential risk factors. Risk factors included patient demographics, Charlson comorbidity score, pre-operative CDI (within 6 months of surgery), recent hospitalization (within 30 days of surgery), and use of corticosteroids, biologics, and immunomodulators (within 30 days of surgery). Inverse-probability of censor weights were used to account for differential follow-up. Age was modeled as a linear variable and centered at 40 years old.
Results: 2,900 patients were included in the analysis. The median follow-up time was 628 days (IQR 287-730). The 2-year cumulative incidence of C. difficile was 3.3% (n=77). Twelve cases (15.6%) occurred during the surgical hospitalization. Patients with previous CDI (HR 7.33, 95% CI 3.85, 13.94) and patients taking corticosteroids (HR 2.19, 95% CI 1.30, 3.71) or biologics (HR 3.59, 95% CI 1.39, 9.24) prior to surgery were significantly more likely to have a CDI after IPAA. No significant differences in the risk of CDI across gender (p=0.51), age (p=0.70), Charlson score (p=0.99), history of recent hospitalization (p=0.50), or immunomodulator use (p=0.30) were seen.
Conclusion: The 2-year incidence of CDI after IPAA is at least 3%. Patients with a history of pre-operative CDI, and those taking corticosteroids or biologics before surgery are more likely to develop a CDI after surgery.
