Multistate modelling to estimate excess length of stay and risk of death associated with organ/space infection after elective colorectal surgery

• Published in: The Journal of hospital infection Vol. 100; no. 4; pp. 400 - 405
• Main Authors: Shaw, E., Gomila, A., Piriz, M., Perez, R., Cuquet, J., Vazquez, A., Badia, J.M., Lérida, A., Fraccalvieri, D., Marron, A., Freixas, N., Castro, A., Cruz, A., Limón, E., Gudiol, F., Biondo, S., Carratalà, J., Pujol, M., Camprubí, D., Martín, L., Sanz, C., Brugués, M., Serra-Aracil, X., Mora, L., Diaz-Brito, V., Moreno, E., Obradors, F., Espejo, E., Aguilar, F., Pagespetit, L., Nicolás, C., Navarro, A., Vazquez, R., Arroyo, N., López, A.F., Iftimie, S.
• Format: Journal Article
• Language: English
• Published: England Elsevier Ltd 01.12.2018
• Subjects: Aged; Colorectal Surgery - adverse effects; Elective colorectal surgery; Female; Hospitals; Humans; Length of Stay; Male; Middle Aged; Models, Statistical; Mortality; Multistate modelling; Organ-space infection; Prospective Studies; Risk Assessment; Spain - epidemiology; Surgical site infection; Surgical Wound Infection - epidemiology; Surgical Wound Infection - mortality; Survival Analysis; Spain; Surgical site infection; Organ-space infection; Multistate modelling; Mortality; Length of stay; Elective colorectal surgery
• ISSN: 0195-6701; 1532-2939
• DOI: 10.1016/j.jhin.2018.08.010

Accounting for time-dependency and competing events are strongly recommended to estimate excess length of stay (LOS) and risk of death associated with healthcare-associated infections. To assess the effect of organ/space (OS) surgical site infection (SSI) on excess LOS and in-hospital mortality in patients undergoing elective colorectal surgery (ECS). A multicentre prospective adult cohort undergoing ECS, January 2012 to December 2014, at 10 Spanish hospitals was used. SSI was considered the time-varying exposure and defined as incisional (superficial and deep) or OS. Discharge alive and death were the study endpoints. The mean excess LOS was estimated using a multistate model which provided a weighted average based on the states patients passed through. Multivariate Cox regression models were used to assess the effect of OS-SSI on risk of discharge alive or in-hospital mortality. Of 2778 patients, 343 (12.3%) developed SSI: 194 (7%) OS-SSI and 149 (5.3%) incisional SSI. Compared to incisional SSI or no infection, OS-SSI prolonged LOS by 4.2 days (95% confidence interval (CI): 4.1–4.3) and 9 days (8.9–9.1), respectively, reduced the risk of discharge alive (adjusted hazard ratio (aHR): 0.36 (95% CI: 0.28–0.47) and aHR: 0.17 (0.14–0.21), respectively), and increased the risk of in-hospital mortality (aHR: 8.02 (1.03–62.9) and aHR: 10.7 (3.7–30.9), respectively). OS-SSI substantially extended LOS and increased risk of death in patients undergoing ECS. These results reinforce OS-SSI as the SSI with the highest health burden in ECS.