Current Literature

Study Defines Risk Factors for CDI, but Results Need to be Interpreted Cautiously

Hess A, Byerly S, Lenart E, Evans C, Kerwin A, Filiberto D. Risk Factors for Clostridium Difficile Infection in General Surgery Patients. Am J Surg. 2023;225(1):118-121. DOI: 10.1016/j.amjsurg.2022.09.031.

Because of the significant influence that C. difficile infection (CDI) has on mortality and morbidity risk in general surgery patients, this study was designed to identify outcomes and features that predict CDI in this patient group. The authors used data from the ACS National Surgical Quality Improvement Program (NSQIP) database to identify 1,840 patients with CDI from a total cohort of 436,831 patients who underwent general surgical procedures.

The overall frequency of CDI was 0.4%. Univariate analysis was used to compare patients who contracted CDI with those who did not have the infection. The data confirmed that patients who develop CDI have significantly increased risks of mortality and prolonged hospital stay. Factors that predicted CDI included non-use of laparoscopic operative technique, older age, emergent procedure, longer time from admission to operation, surgical site infection, deep organ space infection, steroid use, smoking, metastatic cancer, and lower body mass index.

This study provided potentially valuable information, but the results need to be interpreted cautiously because information from databases such as NSQIP may not allow precise matching of risk factors and patient characteristics. Traditionally, prolonged antimicrobial use and administration of multiple antimicrobial agents have been thought to predispose patients to CDI. The facts that higher patient risk, emergent operation, delay to operation, and the presence of active infections were predictive of CDI suggest that antimicrobial use may have played a role in increasing risk of CDI.

Use of 4F-PCC Does Not Appear to Benefit Trauma Patients

Bouzat P, Charbit J, Abback PS, et al. Efficacy and Safety of Early Administration of 4-Factor Prothrombin Complex Concentrate in Patients with Trauma at Risk of Massive Transfusion: The PROCOAG Randomized Clinical Trial. JAMA. 2023. DOI: 10.1001/jama.2023.4080.

Use of aggressive hemorrhage control, early blood transfusion, and administration of platelets and clotting factors as key components of hemorrhagic shock resuscitation in injured patients has become a common pattern of clinical practice. The search for the most effective clotting factor combination for these patients continues.

Supplemental clotting factor agents need to be effective at preventing coagulopathy and have an acceptable risk for venous thromboembolism (VTE). This randomized prospective trial from 12 trauma centers in France compared outcomes in patients receiving 4-factor prothrombin complex concentrate (4F-PCC) with patients who received placebo. Participant surgeons were blinded to the agent administered to included patients.

186 patients received 4F-PCC and 160 received saline placebo. All included patients were severely injured and shock resuscitation was performed using accepted protocols. The outcomes of interest were 24-hour blood transfusion volumes following administration of the designated agent and the frequency of VTE. The data showed that there was no significant difference in 24-hour blood requirements when the two groups were compared; there was a significantly increased risk for VTE in patients receiving 4F-PCC. The authors concluded that 4F-PCC was not associated with patient benefit as a component of hemorrhagic shock resuscitation.