Skip to main content

Advertisement

SpringerLink
Log in

Effect of Inclusion of Oral Antibiotics with Mechanical Bowel Preparation on the Risk of Clostridium Difficile Infection After Colectomy

  • Original Article
  • Published:
Journal of Gastrointestinal Surgery Aims and scope

Abstract

Background/Purpose

While the use of oral antibiotic (OA) for bowel preparation is gaining popularity, it is unknown whether it increases the risk of Clostridium difficile infection (CDI). This study aimed to evaluate the impact of OA on the development of CDI after colectomy.

Methods

Patients who underwent colectomy from the ACS-NSQIP data (2015 and 2016) were included. Patients who received OA as bowel preparation were compared to those who did not with respect to demographics, comorbidities, primary diagnosis, procedure type and approach, and 30-day postoperative complications. Multivariable analysis was performed to characterize the association between OA and CD infection after colectomy. A sub-group analysis was also conducted for patients who did not develop any postoperative infectious complication.

Results

Of 36,374 included patients, 18,177 (50%) received OA and 527 (1.4%) developed CDI for the whole cohort. OA group had more younger, functionally independent and obese patients with lower American Society of Anesthesiologists and wound class. Smoking, diabetes, hypertension, dyspnea or ventilator-dependence, congestive heart failure, disseminated cancer, bleeding disorder, and perioperative transfusion were significantly higher for non-OA group. Mechanical bowel preparation, minimally invasive surgery, conversion to open and operative duration ≥ 180 min were more prevalent in the OA group. The OA group had significantly reduced occurrence of CDI; superficial, deep, and organ space infections; wound disruption; anastomotic leak; reoperation; and infections including sepsis, septic shock, pneumonia, and urinary tract infection. On multivariable analysis, OA reduced the odds for CDI after colectomy (OR = 0.6, 95% CI = [0.5–0.8]). For patients who did not develop infectious postoperative complications, OA was associated with lower risk of CDI (OR = 0.7, CI = [0.5–0.9]). While complications, reoperation, and readmission rates were the same, postoperative ileus and hospital stay were significantly lower for those who developed CDI after receiving OA when compared to non-OA.

Conclusion

The use of OA as bowel preparation may reduce, rather than increase, the risk of 30-day CDI after colectomy. This effect may partly be due to the other recovery advantages associated with oral antibiotics. These data further support current data recommending the use of oral antibiotics for bowel preparation before colectomy.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1

Similar content being viewed by others

References

  1. Miller BA, Chen LF, Sexton DJ, Anderson DJ. Comparison of the burdens of hospital-onset, healthcare facility-associated Clostridium difficile Infection and of healthcare-associated infection due to methicillin-resistant Staphylococcus aureus in community hospitals. Infect Control Hosp Epidemiol. 2011 Apr;32:387–90.

    Article  Google Scholar 

  2. Zilberberg MD, Shorr AF, Kollef MH. Increase in adult Clostridium difficile-related hospitalizations and case-fatality rate, United States, 2000-2005. Emerg Infect Dis. 2008 Jun;14:929–31.

    Article  Google Scholar 

  3. O'Brien JA, Lahue BJ, Caro JJ, Davidson DM. The emerging infectious challenge of clostridium difficile-associated disease in Massachusetts hospitals: clinical and economic consequences. Infect Control Hosp Epidemiol. 2007 Nov;28:1219–27.

    Article  Google Scholar 

  4. Damle RN, Cherng NB, Flahive JM, et al. Clostridium difficile infection after colorectal surgery: a rare but costly complication. J Gastrointest Surg. 2014 Oct;18:1804–11.

    Article  Google Scholar 

  5. Halabi WJ, Nguyen VQ, Carmichael JC, Pigazzi A, Stamos MJ, Mills S. Clostridium difficile colitis in the United States: a decade of trends, outcomes, risk factors for colectomy, and mortality after colectomy. J Am Coll Surg. 2013 Nov;217:802–12.

    Article  Google Scholar 

  6. Aquina CT, Probst CP, Becerra AZ, et al. High Variability in Nosocomial Clostridium difficile Infection Rates Across Hospitals After Colorectal Resection. Dis Colon Rectum. 2016 Apr;59:323–31.

    Article  Google Scholar 

  7. Kiran RP, Murray AC, Chiuzan C, Estrada D, Forde K. Combined preoperative mechanical bowel preparation with oral antibiotics significantly reduces surgical site infection, anastomotic leak, and ileus after colorectal surgery. Ann Surg. 2015 Sep;262:416–25; discussion 423-5.

    Article  Google Scholar 

  8. Althumairi AA, Canner JK, Pawlik TM, et al. Benefits of Bowel Preparation Beyond Surgical Site Infection: A Retrospective Study. Ann Surg. 2016 Dec;264:1051–1057.

    Article  Google Scholar 

  9. Scarborough JE, Mantyh CR, Sun Z, Migaly J. Combined Mechanical and Oral Antibiotic Bowel Preparation Reduces Incisional Surgical Site Infection and Anastomotic Leak Rates After Elective Colorectal Resection: An Analysis of Colectomy-Targeted ACS NSQIP. Ann Surg. 2015 Aug;262:331–7.

    Article  Google Scholar 

  10. Morris MS, Graham LA, Chu DI, Cannon JA, Hawn MT. Oral Antibiotic Bowel Preparation Significantly Reduces Surgical Site Infection Rates and Readmission Rates in Elective Colorectal Surgery. Ann Surg. 2015 Jun;261:1034–40.

    Article  Google Scholar 

  11. Wren SM, Ahmed N, Jamal A, Safadi BY. Preoperative oral antibiotics in colorectal surgery increase the rate of Clostridium difficile colitis. Arch Surg. 2005 Aug;140:752–6.

    Article  CAS  Google Scholar 

  12. Randall JK, Young BC, Patel G, Fitzgerald A, George BD. Is Clostridium difficile infection a particular problem after reversal of ileostomy? Colorectal Dis. 2011 Mar;13:308–11.

    Article  CAS  Google Scholar 

  13. Englesbe MJ, Brooks L, Kubus J, et al. A statewide assessment of surgical site infection following colectomy: the role of oral antibiotics. Ann Surg. 2010 Sep;252:514–9; discussion 519–20.

  14. Krapohl GL, Phillips LR, Campbell DA Jr, et al. Bowel preparation for colectomy and risk of Clostridium difficile infection. Dis Colon Rectum. 2011 Jul;54:810–7.

    Article  Google Scholar 

  15. Klinger AL, Green H, Monlezun DJ, et al. The Role of Bowel Preparation in Colorectal Surgery: Results of the 2012-2015 ACS-NSQIP Data. Ann Surg. 2017 Oct 23.

  16. Khuri SF, Daley J, Henderson W, et al. The Department of Veterans Affairs' NSQIP: the first national, validated, outcome-based, risk-adjusted, and peer-controlled program for the measurement and enhancement of the quality of surgical care. National VA Surgical Quality Improvement Program. Ann Surg. 1998;228:491–507.

    CAS  PubMed  Google Scholar 

  17. Parthasarathy M, Bowers D, Groot-Wassink T. Do pre-operative oral antibiotics increase Clostridium difficile infection rates? An analysis of 13 959 colectomy patients. Colorectal Dis. 2017 Oct 16.

  18. Redelings MD, Sorvillo F, Mascola L. Increase in Clostridium difficile-related mortality rates, United States, 1999-2004. Emerg Infect Dis. 2007 Sep;13:1417–9.

    Article  Google Scholar 

  19. Li X, Wilson M, Nylander W, Smith T, Lynn M, Gunnar W. Analysis of Morbidity and Mortality Outcomes in Postoperative Clostridium difficile Infection in the Veterans Health Administration. JAMA Surg. 2016 Apr;151:314–22. https://doi.org/10.1001/jamasurg.2015.4263.

    Article  PubMed  Google Scholar 

  20. Garfinkle R, Abou-Khalil J, Morin N, et al. Is There a Role for Oral Antibiotic Preparation Alone Before Colorectal Surgery? ACS-NSQIP Analysis by Coarsened Exact Matching. Dis Colon Rectum. 2017 Jul;60:729–737.

    Article  Google Scholar 

  21. Cleary RK, Grossmann R, Fernandez FB, et al. Metronidazole may inhibit intestinal colonization with Clostridium difficile. Dis Colon Rectum. 1998 Apr;41:464–7.

    Article  CAS  Google Scholar 

  22. Krapohl GL, Morris AM, Cai S, et al. Preoperative risk factors for postoperative Clostridium difficile infection in colectomy patients. Am J Surg. 2013 Mar;205:343–7; discussion 347–8.

    Article  Google Scholar 

  23. Al-Mazrou AM, Chiuzan C, Kiran RP. Factors influencing discharge disposition after colectomy. Surg Endosc. 2017 Dec 27. https://doi.org/10.1007/s00464-017-6013-z.

    Article  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Division of Colorectal Surgery, Herbert Irving Pavilion, New York-Presbyterian Hospital/Columbia University Medical Center, 161 Fort Washington Avenue, Floor 8, New York, NY, 10032, USA

    Ahmed M. Al-Mazrou, Laura Z. Hyde, Kunal Suradkar & Ravi P. Kiran

Authors
  1. Ahmed M. Al-Mazrou
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Laura Z. Hyde
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Kunal Suradkar
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Ravi P. Kiran
    View author publications

    You can also search for this author in PubMed Google Scholar

Contributions

Ahmed M. Al-Mazrou and Ravi P. Kiran made substantial contributions to the conception and design of the project as well as acquisition, analysis, and interpretation of data, in addition to manuscript drafting and revising. Laura Z. Hyde made substantial contribution to interpretation of data and manuscript drafting and revising and Kunal Suradkar made substantial contribution to interpretation of data.

Corresponding author

Correspondence to Ravi P. Kiran.

Ethics declarations

Conflict of Interest

The manuscript has been reviewed and approved by all authors and declare no conflict of interest.

Grant Support

No financial/grant support for this work.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Al-Mazrou, A.M., Hyde, L., Suradkar, K. et al. Effect of Inclusion of Oral Antibiotics with Mechanical Bowel Preparation on the Risk of Clostridium Difficile Infection After Colectomy. J Gastrointest Surg 22, 1968–1975 (2018). https://doi.org/10.1007/s11605-018-3837-3

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s11605-018-3837-3

Keywords

Search

Navigation