Study Shows No Link Between NSAIDs and CDI

By DAVID WILD

Non-aspirin nonsteroidal anti-inflammatory drugs (NSAIDs) do not increase the risk for Clostridioides difficile infection (CDI), according to a retrospective review of nearly 1,500 people. The results stand in contrast to prior findings that have suggested an association between NSAID use and CDI.

“To our knowledge, this is the first study of NSAID use as a risk factor for CDI to account for treatment assignment bias utilizing propensity score matching,” noted lead investigator Adam Ressler, MD, from the Department of Internal Medicine, Division of Infectious Disease, at the University of Michigan, in Ann Arbor (Anaerobe 2021 Sep 8. doi:10.1016/j.anaerobe.2021.102444). “This is significant, as it increases our confidence that our modeled risk of CDI is causally related to NSAID use itself, rather than the underlying indication for the NSAID use.”

The authors said prior research on the topic that found an association between NSAID use and CDI “had two major limitations, [including] inadequate assessment of over-the-counter NSAID use and failure to account for treatment assignment bias.”

In this study, Dr. Ressler and his team identified 628 CDI cases from a previously published cohort treated at Michigan Medicine and 628 controls who had diarrhea suspicious for CDI but who tested negative for CDI. They analyzed data for prescribed and over-the-counter non-aspirin NSAID use within 30 days of CDI, as well as comorbidities and baseline laboratory findings.

To overcome the weaknesses of prior research, patients with CDI and NSAID use were closely matched with nonCDI NSAID users according to sex, presence of back pain and arthritis, baseline serum creatinine, serum albumin, and use of anticoagulants for antiplatelet medications.

The investigators found that 22% to 26% of those with or without CDI had used non-aspirin NSAIDs during the previous month, with analyses confirming there was no elevated CDI risk among those receiving NSAIDs (odds ratio [OR], 0.97; 95% CI, 0.72-1.29; P=0.816).

The only significant risk factors for CDI they found were older age (OR, 1.09; CI, 1.01-1.17; P=0.02), scores on the weighted Elixhauser Comorbidity Index, a measure of comorbidity burden (OR, 0.98; 95% CI, 0.97-0.99) and prior CDI (OR, 2.64; 95% CI, 1.96-3.56).

Dr. Ressler and his colleagues concluded that their “findings do not support an association between NSAID use and an increased risk for CDI.” ■

Patient Safety Tips

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patients, Ms. Horvath said. It’s important for institutions to review and optimize their protocols to inspect and maintain equipment, regularly train staff on the use of equipment, and establish a process for responding to and reporting equipmentrelated events, both within and outside the facility, she said.

Wrong Site, Wrong Patient

Less than 4% of reported incidents involved surgeries performed on the wrong patient or on the wrong surgical site, but that’s no reason to become complacent, Ms. Horvath said. “Just because something didn’t happen to you before doesn’t mean it’s not going to happen today,” she said. “Things that never happened before happen every single day.” Institutions must develop rigorous policies and procedures to prevent such a grave mistake, she noted, and ensure staff remain vigilant, and aren’t just checking safety steps off a checklist.

When it comes to surgical patient safety, the key factors are communication and commitment to an accountable culture, said Dr. Spruce. This way, surgical staff can communicate safety concerns and learn from their mistakes. “The pillars of a patient safety culture are ‘trust, report and improve,’ and these provide a foundation for healthcare organizations to achieve high levels of patient safety.” ■

Mesh Removal

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“Based on [what the authors say], open repair is always going to be the procedure of choice for meshes that were placed anteriorly. In these cases, open removal was as good as robotic,” said Kamal Itani, MD, the chief of surgery at VA Boston Health Care System, a professor of surgery at Boston University and a faculty member at Harvard Medical School, who was not involved with the study. “It then becomes a comparison between the laparoscopic and robotic approach for posteriorly placed meshes. Although the surgery was longer with the robot, there were less complications with the robotic approach compared to laparoscopic. The numbers are too small, and possible confounders too many to reach solid conclusions. However, [this study] could be hypothesis-generating for a larger prospective multicenter study looking at laparoscopic versus robotic explantation of meshes in patients that had posteriorly placed mesh.”

Dr. Huynh noted that mesh removal is safe and effective for treating chronic postoperative inguinal pain in the right patients, regardless of the approach taken. “Due to the reoperative setting and distorted anatomy, these cases should be approached judiciously by surgeons who are practiced in it,” Dr. Huynh said. “Based on our group’s own experience and trends in this data set, we prefer a robotic approach when appropriate. However, we continue to regularly employ the open and laparoscopic techniques when necessary.” ■