Evaluation of Risk Factors for a Fulminant Clostridium Difficile Infection After Cardiac Surgery

A Single-center, Retrospective Cohort Study

Maximilian Vondran; Senta Schack; Jens Garbade; Christian Binner; Meinhard Mende; Ardawan Julian Rastan; Michael Andrew Borger; Thomas Schroeter


BMC Anesthesiol. 2018;18(133) 

In This Article


Table 2 summarizes all pre-operative patient characteristics. A total of 1256 patients (3.0% of cardiac surgery patients) developed a post-operative CDI between April 1999 and April 2011. Of these, 153 (12.2%) developed a fulminant CDI during their stay. The patients with a fulminant CDI had a significantly lower pre-operative LVEF than that of the group with a bland CDI. Furthermore, the pre-operative proportion of patients with diabetes mellitus, LVEF < 30%, age > 80 years, prior cardiac surgery, ventilator dependence, and a poor NYHA functional class was significantly higher for the group developing a fulminant CDI.

Table 3 summarizes all peri-procedural details. The duration of surgery, cardiopulmonary bypass (CPB) time, cross-clamp time, and time of reperfusion were significantly longer for the patients with a fulminant CDI. The percentage of patients needing emergency surgery was also significantly higher in the group with a fulminant CDI, whereas minimally invasive surgery was performed significantly more often in the group with bland CDI.

Table 4 summarizes post-operative outcomes. The post-operative course of the patients with a fulminant CDI was associated with more complications. This group required mechanical circulatory assist devices (MCAD) significantly more often. Whereas the bland CDI group needed MCAD in just 4.6% (n = 51) of cases, MCAD was required in 19.0% (n = 51) of patients with a fulminant course. The proportion of intra-aortic balloon pump (IABP) support as MCAD was 93.1% in the fulminant CDI group and 80.4% in the bland CDI group. (p = 0.221). Moreover, renal replacement therapy, re-intubation, and a tracheostomy was required significantly more often in the group with fulminant CDI. Furthermore, post-operative neurological dysfunction was diagnosed more frequently in the patients with a fulminant CDI. The utilization of RBC concentrates, FFP units, and platelet concentrates was significantly greater for the patients with a fulminant CDI, and these patients were ventilated longer and the length of ICU or intermediate care unit stay was significantly longer.

The 30-day all-cause mortality was 6.1% (n = 77) and overall all-cause mortality was 27.7% (n = 348) for the entire study cohort. Patients with a fulminant CDI had a significantly higher 30-day all-cause mortality rate than patients with a bland CDI (21.6% vs. 4.0%, p < 0.001). Moreover, the overall all-cause mortality was significantly higher for patients with a fulminant CDI (63.4% vs. 22.8%, p < 0.001; Figure 1). The median follow-up time was 8 (interquartile range: 2; 30) months. Diabetes mellitus type 2, pre-operative ventilation, utilization of more than 8 RBC concentrates, more than 5 FFP units, and a cross-clamp time > 130 min were multiple independent predictors of a fulminant CDI (Table 5).

Figure 1.

Cumulative survival of patients with bland CDI vs. fulminant CDI