Fajnzylber, Jesse

Abstract Background: Clostridioides difficile infection (CDI) requiring colectomy carries substantial mortality risk, with optimal timing of surgery remaining poorly defined. We examined temporal trends in colectomy among inpatients with CDI, identified predictors of surgical intervention and postoperative mortality, and evaluated the association between surgical timing and patient outcomes. Methods: A retrospective cohort study was conducted using the National Inpatient Sample database from 2018 to 2022. We compared patients undergoing colectomy with those managed medically. To minimize confounding by hospital-onset cases, the analysis of surgical timing and mortality was restricted to patients undergoing colectomy within 8 days of admission. Predictors were identified using survey-weighted logistic regression and LASSO regression models. Results: Among 240,564 CDI hospitalizations (representing 1,207,995 weighted nationally), 717 patients underwent colectomy (3,585 weighted). CDI prevalence declined from 0.99% (2018) to 0.76% (2022), while colectomy rates increased from 0.28% to 0.34%. Peritonitis (OR 5.42; 95% CI, 4.46–6.59), coagulopathy (OR 4.96; 95% CI, 3.76–6.55), and sepsis/septic shock (OR 3.89; 95% CI, 3.39–4.47) were the strongest predictors of colectomy. Among patients undergoing colectomy within 8 days (2,830 weighted), in-hospital mortality was 26.5% overall, increasing from 21.0% (2018) to 30.7% (2022). Sepsis/septic shock (OR 8.20; 95% CI 2.92–23.07) and coagulopathy (OR 7.27; 95% CI 3.31–15.97) predicted mortality. Each additional day from admission to colectomy was associated with a 16% (OR 1.16; 95% CI 1.04–1.28) increased mortality risk. Conclusions: In this nationally representative cohort, surgical timing was an independent and modifiable determinant of survival in patients with CDI requiring colectomy. Our findings underscore the importance of early surgical consultation for CDI patients with peritonitis, sepsis, and coagulopathy.