Clinical Orthopaedics and Related Research®

, Volume 471, Issue 10, pp 3178–3185

Clostridium difficile Colitis in Patients Undergoing Lower-extremity Arthroplasty: Rare Infection With Major Impact

  • Mitchell Gil Maltenfort
  • Mohammad R. Rasouli
  • Todd A. Morrison
  • Javad Parvizi
Symposium: 2012 Musculoskeletal Infection Society



The prevalence of Clostridium difficile colitis is reportedly increasing in surgical patients and can negatively impact their outcome. However, as yet there are no clear estimates of the C difficile infection colitis rate and its consequences among patients undergoing total joint arthroplasty (TJA).


We asked: (1) What is the rate of C difficile colitis in TJA patients? (2) What are the risk factors of C difficile colitis in these patients? And (3) what is the effect of C difficile colitis on length of stay, in-hospital mortality, and estimated total charges?


Using ICD-9-CM diagnosis and procedure codes, we queried the Nationwide Inpatient Sample database for patients undergoing TJA for the years 2002 to 2010. Demographic data, comorbidities, occurrence of C difficile colitis, length of hospital stay, mortality, and hospital charges were extracted. Logistic regression was performed to identify predictors of C difficile colitis and its impact on in-hospital mortality.


The incidence of C difficile remained less than 0.6% during the study period. Revision TJAs (odds ratio = 6.9 and 4.4 for hip and knee, respectively) and number of comorbidities (odds ratio = 1.5) increased risk of C difficile colitis. C difficile increased length of hospital stay by a week, hospital charges by USD 40,000, and in-hospital mortality to 4.66% from 0.24%.


Using lower and fewer doses of antibiotics in revision TJAs and among patients with many comorbidities may diminish risk of C difficile colitis and its consequent mortality.

Level of Evidence

Level II, prognostic study. See Instructions for Authors for a complete description of levels of evidence.


  1. 1.
    Agency for Healthcare Research and Quality. Healthcare Cost & Utilization Project: database and related tools from HCUP. Available at: Accessed February 18, 2013.
  2. 2.
    Al-Obaydi W, Smith CD, Foguet P. Changing prophylactic antibiotic protocol for reducing Clostridium difficile-associated diarrhoeal infections. J Orthop Surg (Hong Kong). 2010;18:320–323.PubMedGoogle Scholar
  3. 3.
    Badger VO, Ledeboer NA, Graham MB, Edmiston CE Jr. Clostridium difficile: epidemiology, pathogenesis, management, and prevention of a recalcitrant healthcare-associated pathogen. JPEN J Parenter Enteral Nutr. 2012;36:645–662.PubMedCrossRefGoogle Scholar
  4. 4.
    Bobo LD, Dubberke ER, Kollef M. Clostridium difficile in the ICU: the struggle continues. Chest. 2011;140:1643–1653.PubMedCrossRefGoogle Scholar
  5. 5.
    Bottle A, Aylin P. Comorbidity scores for administrative data benefited from adaptation to local coding and diagnostic practices. J Clin Epidemiol. 2011;64:1426–1433.PubMedCrossRefGoogle Scholar
  6. 6.
    Bureau of Labor Statistics. CPI inflation calculator. Available at: Accessed February 27, 2013.
  7. 7.
    Carignan A, Allard C, Pépin J, Cossette B, Nault V, Valiquette L. Risk of Clostridium difficile infection after perioperative antibacterial prophylaxis before and during an outbreak of infection due to a hypervirulent strain. Clin Infect Dis. 2008;46:1838–1843.PubMedCrossRefGoogle Scholar
  8. 8.
    Carr AJ, Robertsson O, Graves S, Price AJ, Arden NK, Judge A, Beard DJ. Knee replacement. Lancet. 2012;379:1331–1340.PubMedCrossRefGoogle Scholar
  9. 9.
    Chu YT, Ng YY, Wu SC. Comparison of different comorbidity measures for use with administrative data in predicting short- and long-term mortality. BMC Health Serv Res. 2010;10:140.PubMedCrossRefGoogle Scholar
  10. 10.
    Clarke HJ, Jinnah RH, Byank RP, Cox QG. Clostridium difficile infection in orthopaedic patients. J Bone Joint Surg Am. 1990;72:1056–1059.PubMedGoogle Scholar
  11. 11.
    Csikesz NG, Nguyen LN, Tseng JF, Shah SA. Nationwide volume and mortality after elective surgery in cirrhotic patients. J Am Coll Surg. 2009;208:96–103.PubMedCrossRefGoogle Scholar
  12. 12.
    Elixhauser A, Steiner C, Harris DR, Coffey RM. Comorbidity measures for use with administrative data. Med Care. 1998;36:8–27.PubMedCrossRefGoogle Scholar
  13. 13.
    Forster AJ, Taljaard M, Oake N, Wilson K, Roth V, van Walraven C. The effect of hospital-acquired infection with Clostridium difficile on length of stay in hospital. CMAJ. 2012;184:37–42.PubMedGoogle Scholar
  14. 14.
    Jawa RS, Mercer DW. Clostridium difficile-associated infection: a disease of varying severity. Am J Surg. 2012;204:836–842.PubMedCrossRefGoogle Scholar
  15. 15.
    Jenkins PJ, Teoh K, Simpson PM, Dave J, Simpson AH, Breusch S. Clostridium difficile in patients undergoing primary hip and knee replacement. J Bone Joint Surg Br. 2010;92:994–998.PubMedCrossRefGoogle Scholar
  16. 16.
    Jobe BA, Grasley A, Deveney KE, Deveney CW, Sheppard BC. Clostridium difficile colitis: an increasing hospital-acquired illness. Am J Surg. 1995;169:480–483.PubMedCrossRefGoogle Scholar
  17. 17.
    Kaplan GG, Hubbard J, Panaccione R, Shaheen AA, Quan H, Nguyen GC, Dixon E, Ghosh S, Myers RP. Risk of comorbidities on postoperative outcomes in patients with inflammatory bowel disease. Arch Surg. 2011;146:959–964.PubMedCrossRefGoogle Scholar
  18. 18.
    Kirksey M, Chiu YL, Ma Y, Della Valle AG, Poultsides L, Gerner P, Memtsoudis SG. Trends in in-hospital major morbidity and mortality after total joint arthroplasty: United States 1998–2008. Anesth Analg. 2012;115:321–327.PubMedCrossRefGoogle Scholar
  19. 19.
    Kurd MF, Pulido L, Joshi A, Purtill JJ, Parvizi J. Clostridium difficile infection after total joint arthroplasty: who is at risk? J Arthroplasty. 2008;23:839–842.PubMedCrossRefGoogle Scholar
  20. 20.
    Kurtz S, Ong K, Lau E, Mowat F, Halpern M. Projections of primary and revision hip and knee arthroplasty in the United States from 2005 to 2030. J Bone Joint Surg Am. 2007;89:780–785.PubMedCrossRefGoogle Scholar
  21. 21.
    Kyne L, Warny M, Qamar A, Kelly CP. Asymptomatic carriage of Clostridium difficile and serum levels of IgG antibody against toxin A. N Engl J Med. 2000;342:390–397.PubMedCrossRefGoogle Scholar
  22. 22.
    Lix LM, Quail J, Teare G, Acan B. Performance of comorbidity measures for predicting outcomes in population-based osteoporosis cohorts. Osteoporos Int. 2011;22:2633–2643.PubMedCrossRefGoogle Scholar
  23. 23.
    McFarland LV, Mulligan ME, Kwok RY, Stamm WE. Nosocomial acquisition of Clostridium difficile infection. N Engl J Med. 1989;320:204–210.PubMedCrossRefGoogle Scholar
  24. 24.
    Morris AM, Jobe BA, Stoney M, Sheppard BC, Deveney CW, Deveney KE. Clostridium difficile colitis: an increasingly aggressive iatrogenic disease? Arch Surg. 2002;137:1096–1100.PubMedCrossRefGoogle Scholar
  25. 25.
    Pivec R, Johnson AJ, Mears SC, Mont MA. Hip arthroplasty. Lancet. 2012;380:1768–1777.PubMedCrossRefGoogle Scholar
  26. 26.
    Ricciardi R, Rothenberger DA, Madoff RD, Baxter NN. Increasing prevalence and severity of Clostridium difficile colitis in hospitalized patients in the United States. Arch Surg. 2007;142:624–631.PubMedCrossRefGoogle Scholar
  27. 27.
    Sharabiani MT, Aylin P, Bottle A. Systematic review of comorbidity indices for administrative data. Med Care. 2012;50:1109–1118.PubMedCrossRefGoogle Scholar
  28. 28.
    Sharma P, Bomireddy R, Phillips S. Clostridium difficile-associated diarrhoea after internal fixation of intertrochanteric femoral fractures. Eur J Clin Microbiol Infect Dis. 2003;22:615–618.PubMedCrossRefGoogle Scholar
  29. 29.
    Shen Y, Silverstein JC, Roth S. In-hospital complications and mortality after elective spinal fusion surgery in the United States: a study of the nationwide inpatient sample from 2001 to 2005. J Neurosurg Anesthesiol. 2009;21:21–30.PubMedCrossRefGoogle Scholar
  30. 30.
    Slobogean GP, Kennedy SA, Davidson D, O’Brien PJ. Single- versus multiple-dose antibiotic prophylaxis in the surgical treatment of closed fractures: a meta-analysis. J Orthop Trauma. 2008;22:264–269.PubMedCrossRefGoogle Scholar
  31. 31.
    Stewart DB, Hollenbeak CS. Clostridium difficile colitis: factors associated with outcome and assessment of mortality at a national level. J Gastrointest Surg. 2011;15:1548–1555.PubMedCrossRefGoogle Scholar
  32. 32.
    Wang L, Stewart DB. Increasing hospital costs for Clostridium difficile colitis: type of hospital matters. Surgery. 2011;150:727–735.PubMedCrossRefGoogle Scholar
  33. 33.
    Yam FK, Smith KM. “Collateral damage”: antibiotics and the risk of Clostridium difficile infection. Orthopedics. 2005;28:275–279.PubMedGoogle Scholar
  34. 34.
    Zerey M, Paton BL, Lincourt AE, Gersin KS, Kercher KW, Heniford BT. The burden of Clostridium difficile in surgical patients in the United States. Surg Infect. 2007;8:557–566.CrossRefGoogle Scholar

Copyright information

© The Association of Bone and Joint Surgeons® 2013

Authors and Affiliations

  • Mitchell Gil Maltenfort
    • 1
  • Mohammad R. Rasouli
    • 1
  • Todd A. Morrison
    • 1
  • Javad Parvizi
    • 1
  1. 1.The Rothman Institute of Orthopedics at Thomas Jefferson HospitalPhiladelphiaUSA

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