Clostridium difficile infection after cardiac surgery: Prevalence, morbidity, mortality, and resource utilization Suresh Keshavamurthy, MBBS, MS, Colleen.

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Presentation transcript:

Clostridium difficile infection after cardiac surgery: Prevalence, morbidity, mortality, and resource utilization Suresh Keshavamurthy, MBBS, MS, Colleen G. Koch, MD, MS, MBA, Thomas G. Fraser, MD, Steven M. Gordon, MD, Penny L. Houghtaling, MS, Edward G. Soltesz, MD, MPH, Eugene H. Blackstone, MD, Gösta B. Pettersson, MD, PhD The Journal of Thoracic and Cardiovascular Surgery Volume 148, Issue 6, Pages 3157-3165.e5 (December 2014) DOI: 10.1016/j.jtcvs.2014.08.017 Copyright © 2014 The American Association for Thoracic Surgery Terms and Conditions

Figure 1 Occurrence of in-hospital Clostridium difficile infection (CDI) after cardiac surgery. The Journal of Thoracic and Cardiovascular Surgery 2014 148, 3157-3165.e5DOI: (10.1016/j.jtcvs.2014.08.017) Copyright © 2014 The American Association for Thoracic Surgery Terms and Conditions

Figure 2 Characterization of onset of Clostridium difficile infection (CDI) after cardiac surgery. A, Distribution of the number of days between cardiac surgery and diagnosis. B, Instantaneous in-hospital risk of CDI after cardiac surgery. Solid line is parametric hazard enclosed within a dashed 68% confidence band equivalent to ±1 standard error (SE). C, Occurrence of CDI. Each symbol represents a diagnosis positioned on the vertical axis by the Kaplan-Meier estimator, and vertical bars are confidence limits equivalent to ±1 standard error. Solid line is parametric prevalence enclosed within a dashed 68% confidence band equivalent to ±1 SE. The Journal of Thoracic and Cardiovascular Surgery 2014 148, 3157-3165.e5DOI: (10.1016/j.jtcvs.2014.08.017) Copyright © 2014 The American Association for Thoracic Surgery Terms and Conditions

Figure 3 Survival of propensity-matched patients stratified by whether or not the patient had a Clostridium difficile infection (CDI). Time zero for the upper curve is the date of surgery, with patients censored at occurrence of CDI (competing-risks analysis). Time zero for the lower curve is the time of CDI diagnosis. Each symbol represents a death, vertical bars are 68% confidence limits equivalent to ± 1 standard error, and solid lines are parametric estimates enclosed within a 68% confidence band. The Journal of Thoracic and Cardiovascular Surgery 2014 148, 3157-3165.e5DOI: (10.1016/j.jtcvs.2014.08.017) Copyright © 2014 The American Association for Thoracic Surgery Terms and Conditions

Figure E1 Covariable balance description before (triangles) and after (squares) matching between the no CDI and CDI groups.* HDL, High-density lipoprotein; LVEF, left ventricular ejection fraction; clr, clearance; IDDM, insulin-dependent diabetes; CABG, coronary artery bypass grafting; CAD, coronary artery disease; BUN, blood urea nitrogen; COPD, chronic obstructive pulmonary disease; NYHA, New York Heart Association; CPB, cardiopulmonary bypass; OR, operating room; CDI, Clostridium difficile infection. *Austin PC, Mamdani MM. A comparison of propensity score methods: a case study estimating the effectiveness of post-AMI statin use. Stat Med. 2006;25:2084-106. The Journal of Thoracic and Cardiovascular Surgery 2014 148, 3157-3165.e5DOI: (10.1016/j.jtcvs.2014.08.017) Copyright © 2014 The American Association for Thoracic Surgery Terms and Conditions

Figure E2 Characterization of the onset of Clostridium difficile infection (CDI) after cardiac surgery. Days between peak white blood cell (WBC) count and diagnosis of CDI. The Journal of Thoracic and Cardiovascular Surgery 2014 148, 3157-3165.e5DOI: (10.1016/j.jtcvs.2014.08.017) Copyright © 2014 The American Association for Thoracic Surgery Terms and Conditions

Figure E3 Unadjusted survival stratified by whether or not the patient had a Clostridium difficile infection (CDI). Time zero for the upper curve is the date of surgery, with patients censored at occurrence of CDI. Time zero for the lower curve is the time of the CDI diagnosis. Each symbol on the lower curve represents a death positioned on the vertical axis by the Kaplan-Meier estimator, and vertical bars are confidence limits equivalent to ±1 standard error. The solid line for both curves is parametric survival enclosed within a dashed 68% confidence band. The number of patients at risk is given below the horizontal axis. The Journal of Thoracic and Cardiovascular Surgery 2014 148, 3157-3165.e5DOI: (10.1016/j.jtcvs.2014.08.017) Copyright © 2014 The American Association for Thoracic Surgery Terms and Conditions

Figure E4 Effect of continuous risk factors on the probability of developing Clostridium difficile (CDI) infection using nomograms of the logistic regression equation. Solid lines are parametric estimates enclosed within a 68% confidence band. Simulations are based on the logistic model (Table 3) for a 65-year-old patient with hypertension, no chronic obstructive pulmonary disease, high-density lipoprotein (HDL) level 48 mg/dL, creatinine level 1.0 mg/dL, no hospital transfer, and no ventricular assist device, stratified by use of blood products. A, Age at operation. B, Preoperative HDL level. C, Preoperative creatinine level. D, Red blood cell (RBC) units transfused. E, Date of operation. The Journal of Thoracic and Cardiovascular Surgery 2014 148, 3157-3165.e5DOI: (10.1016/j.jtcvs.2014.08.017) Copyright © 2014 The American Association for Thoracic Surgery Terms and Conditions