Clostridium difficile Infection Is Rare But Costly/Deadly Complication in Cervical Spine Surgery

Commentary by lead author Sheeraz A. Qureshi, MD; and Domagoj Coric, MD, Chief, Department of Neurosurgery, Carolinas Medical Center

Clostridium difficile infection occurs in approximately 0.08% of patients following postoperative cervical spine surgery and is associated with an increased risk of in-hospital mortality and costs of more than $6.5 million per year, according to data from a retrospective database analysis.

Clostridium difficile bacteria
The study findings suggest that "C. difficile is something that spine surgeons need to consider when managing their patients, especially in the postoperative period," said senior author Sheeraz A. Qureshi, MD, who is Associate Professor of Spinal Surgery at Mount Sinai Medical Center in New York, NY. Surgeons best avoid C. difficile infection in these patients by following guidelines for antibiotic usage, Dr. Qureshi said.

The investigators used the 2002 to 2011 Nationwide Inpatient Sample (NIS) database to identify cases of C. difficile following cervical spine procedures for degenerative spine diagnoses.

C. difficile Infection Occurs in Less Than 1% of Cervical Spine Procedures
Of 1,602,130 patients who underwent applicable cervical spine surgeries, 1,270 patients were hospitalized with a concurrent C. difficile diagnosis. Independent risk factors for C. difficile infection are shown in the Table. The cost for infected patients was $6,830,695 was per year.

Independent risk factors associated with increased  risk of clostridium difficile after cervical spine surgery
C difficile Infections Increase Mortality Rate
A total of 101 infected patients died. The mortality rate in these patients was significantly higher than in patients who did not have C. difficile infection (8% vs 0.19%; P<0.0001), and C. difficile infection was a significant predictor of inpatient mortality (odds ratio, 3.99; P<0.0001).

Dr. Qureshi hopes that the study will result in less empiric antibiotic usage in spine surgery patients and emphasized that "C. diff can affect any patient undergoing spine surgery."

"Thankfully, [C difficile infection] is not common, but there are ways that as surgeons, we can further reduce its incidence," Dr. Qureshi said.


Domagoj Coric, MD
Chief, Department of Neurosurgery, Carolinas Medical Center
Spine Director, Neuroscience Institute, Carolinas Healthcare System
Board Member, International Society for the Advancement of Spine Surgery (ISASS)
Carolina Neurosurgery & Spine Associates

This study is a retrospective review of the Nationwide Inpatient Sample database. Therefore, it reviews a large number of cases (over 1.6 million). But, it is limited in the perioperative data that is collected. For instance, there is no data on what antibiotics and how many doses were administered, and whether Surgical Care Improvement Project (SCIP) measures were actually followed.

Although C. difficile infections are serious and the incidence of these infections has risen, it is still a rare complication (less than 1 in 1,000 prevalence) in cervical spine surgery. The best way to avoid C. difficile infection is to limit prophylactic antibiotics and to follow SCIP evidence-based recommendations as to antibiotic type, dose, and timing. The best way to limit the morbidity associated with C. difficile infection is for surgeons to be aware of high-risk patients (eg, congestive heart failure and renal failure patients) and to be aware of the proper diagnosis and treatment of C. difficile infection.

Although this study does not provide any new, ground-breaking information, it does highlight the severity of C. difficile infection and its concomitant costs, both in terms of patient morbidity and healthcare dollars. It also highlights the importance of recognizing high-risk populations and limiting antibiotic use to evidence-based guidelines (ie, SCIP measures).

Updated on: 07/05/16
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