Impact of changes in antibiotic policy on Clostridium difficile-associated diarrhoea (CDAD) over a five-year period in a district general hospital

doi:10.1016/S0195-6701(03)00115-4

Journal of Hospital Infection

Volume 54, Issue 2, June 2003, Pages 104-108

https://doi.org/10.1016/S0195-6701(03)00115-4 Get rights and content

Abstract

The impact of changes in antibiotic policy on Clostridium difficile-associated diarrhoea (CDAD), over a five-year period between 1995 and 2000, were studied in the Preston Acute Hospitals Trust. In 1996 the policy was changed in the Preston Acute Hospitals Trust from cefotaxime to ceftriaxone for initial treatment of severe sepsis or pneumonia in medical patients. Over the next nine months the average number of patients with C. difficile toxin–positive stools per quarter increased from 16 to 39. The predicted use of ceftriaxone exceeded by 65% an estimate based on prior use of cefotaxime. A policy of restricted duration of ceftriaxone was introduced, and although this reduced usage by over 50%, CDAD continued at an average of 9.2 cases per month, despite withdrawal of oral cephalosporins in December 1998. In August 1999 levofloxacin was substituted for ceftriaxone in the policy. The incidence of CDAD fell progressively to five cases per month by 2000. It would appear that a short (typically three dose) course of third-generation cephalosporin poses a similar risk for CDAD as a more prolonged course. The six-month delay in the decline of CDAD after virtual withdrawal of cephalosporins may reflect a slowly diminishing environmental reservoir.

Introduction

Clostridium difficile-associated diarrhoea (CDAD) is a common iatrogenic, nosocomial disease associated with substantial morbidity and mortality CDAD is endemic in hospitals and long-term care facilities throughout the world and more than 16 000 cases were notified in England and Wales¹ in 1997–1998. The spectrum of disease is wide, ranging from asymptomatic carriage through mild diarrhoea to pseudomembranous colitis. CDAD is a substantial burden on the health service, both in terms of direct costs, longer hospital stay and possible ward closures. The annual cost of C. difficile infection to an averaged-sized district general hospital has been calculated to be approximately £400 000 which includes 2100 lost bed days.²

Overuse of antibiotics particularly the second- and third-generation cephalosporins is a major risk factor predisposing to CDAD.4., 5. A hospital confronted with the problem of CDAD can employ several approaches towards its control. These include limiting the use of antibiotics, prompt isolation, hand washing between contact with all patients, use of enteric precautions and environmental hygiene. Since antibiotic exposure has been recognized to be of primary importance in CDAD, an effective antibiotic policy, which minimizes the use of agents with a marked propensity to cause this problem, is a key preventative measure. In this report we describe the impact of changes made to the antibiotic policy, with the objective of controlling CDAD, over a five-year period between 1995 and 2000.

Section snippets

Location

Preston Acute Hospitals Trust (PAHT) comprises approximately 800 beds at Royal Preston and Sharoe Green hospitals, which together serve the local population for general health services and a wider population for specialist health services across Lancashire and South Cumbria. The Trust houses the regional centre for neurosurgery, neurology, renal medicine, burns, plastic surgery, oncology and disablement services.

Patients

Study population comprised inpatients between 1995 and 2000 at PAHT with diarrhoea

Results

The trend in incidence of CDAD over the study period is shown in Figure 1. A sharp increase in number of CDAD cases was noted following introduction of ceftriaxone on the medical wards in 1996. Over the next nine months the number of patients on the medical wards with C. difficile toxin-positive stools per quarter increased from 16 to 39. This led to efforts aimed at restricting the use of ceftriaxone. An improvement was observed through out 1997, but this was not sustained in 1998–1999. The

Discussion

A rise in CDAD has been observed as a national trend in recent years and several hospitals have already curtailed the use of cephalosporins in an attempt to control this rise, with apparent success.⁵ The problem posed by CDAD at PAHT became intensified in late 1996, after the cephalosporin recommended in the antibiotic policy was changed from cefotaxime to ceftriaxone for initial treatment of severe sepsis or pneumonia in medical patients. While ceftriaxone is not generally regarded to have an

Acknowledgements

We thank Mrs Barbara Healey, Pharmacy dept and Mr Michael Turner, information analysis dept Royal Preston Hospital for their contribution in the study.

References (10)

J.M. Starr et al.
Hospital-acquired Clostridium difficile diarrhoea and herd immunity
Lancet
(1997)
E.M. Jones et al.
Hospital acquired Clostridium difficile diarrhoea
Lancet
(1997)
Clostridium difficile in England and Wales—weeks 1-26/99
Commun Dis Rep CDR Wkly
(1999)
M.H. Wilcox
Clostridium difficile infection: appendix
J Antimicrob Chemother
(1998)
C.D. Settle et al.
Prospective study of the risk of Clostridium difficile diarrhoea in elderly patients following treatment with cefotaxime or piperacillin–tazobactam
Aliment Pharmacol Therapeut
(1998)

There are more references available in the full text version of this article.

Cited by (89)

Reprint of: Overview and changing epidemiology of Clostridium difficile infection
2018, Seminars in Colon and Rectal Surgery
There has been an increase in Clostridium difficile infection (CDI) incidence, severity, and mortality during the last decade. Although the elderly receiving antibiotic therapy are the most common group at risk for infection, CDI occurs in all age groups, and recent data indicate that CDI is emerging in groups that have been traditionally considered at low risk for infection. Additionally, approximately one-third of all CDI cases are now considered to be community associated in the U.S. New information is emerging on risk factors for an initial episode of CDI as well as recurrent disease. Increases in the burden of disease and severe outcomes related to CDI has been associated with the emergence of a new epidemic strain, restriction enzyme analysis BI, North American Pulsed-Field Type 1, and PCR Ribotype 027 (BI/NAP1/027) as well as other emerging strains. This article explores the changing epidemiology of CDI based on the latest available data as well as the recent developments in diagnosis and infection control.
Heterogeneity in application, design, and analysis characteristics was found for controlled before-after and interrupted time series studies included in Cochrane reviews
2017, Journal of Clinical Epidemiology
The aim of the study was to examine the application, design, and analysis characteristics of controlled before-after (CBA) and interrupted time series (ITS) studies and their use in Cochrane reviews.
We searched the Cochrane library for reviews including these study designs from May 2012 to March 2015 and purposively selected, where available, two reviews each across 10 prespecified intervention types. We randomly selected two CBA and two ITS studies from each review. Two researchers independently extracted information from the studies and the respective reviews.
Sixty-nine reviews considered CBA and ITS studies for inclusion. We analyzed 21 CBA and 16 ITS studies from 11 to 8 reviews, respectively. Cochrane reviews inconsistently defined and labeled CBA and ITS studies. Many studies did not meet the Cochrane definition or the minimum criteria provided by Cochrane Effective Practice and Organisation of Care. The studies present a heterogeneous set of study features and applied a large variety of analyses.
While CBA and ITS studies represent important study designs to evaluate the effects of interventions, especially on a population or organizational level, unclear study design features challenge unequivocal classification and appropriate use. We discuss options for more specific definitions and explicit criteria for CBA and ITS studies.
Good epidemiological practice: a narrative review of appropriate scientific methods to evaluate the impact of antimicrobial stewardship interventions
2017, Clinical Microbiology and Infection
In this narrative review, we provide a framework for assessing the quality of evidence provided by studies investigating antimicrobial stewardship (AMS) interventions, and inform the design and planning stage for future AMS evaluation studies to determine the best strategies to keep antimicrobial resistance at bay.
Cochrane/Pubmed.
As AMS is mostly applied in a complex, real-world setting, bias and random time effects can jeopardize the validity of causal inference. The most important risks include simultaneously implemented infection prevention strategies and regression to the mean. Inclusion of homogeneous intervention and control arms, through randomization of the intervention, can limit these risks. However, contamination can play an important role for AMS; therefore, randomization at cluster-level, instead of randomization at individual-level, is recommended. It can be challenging to identify enough representative clusters, and implementation of a cluster-RCT (cRCT) can be costly. Controlled interrupted time series (ITS) design has a high validity as well, and is relatively straightforward to implement, although time-varying confounding should be considered. Independent of the study design, it is crucial to include multiple process, clinical outcome, microbiological and financial measures, to be able to detect possible, unintended consequences.
Future studies assessing the impact of new AMS strategies should produce compelling evidence by opting for cRCTs, or ITS including a control arm. Furthermore, a holistic view of intended and unintended consequences should be reported, and a detailed process evaluation should be provided to adequately inform implementation of successful AMS strategies to battle the rising burden of AMR.
Introduction to biomaterials and medical device-associated infections
2015, Biomaterials and Medical Device - Associated Infections
The use of medical devices to alleviate patient suffering is common practice in modern medicine. Such devices can incorporate chemicals to reduce microbial colonisation in an attempt to decrease infection rates. However, the prolonged and unnecessary use of medical devices has been linked to an increase in microbial resistance to antibiotics, and means that the patient might have to undergo a secondary treatment, sometimes requiring surgery to remove an infected implant. This chapter will briefly explore the history of biomedical devices, moving on to discuss the contemporary use of smart materials to deliver site-specific responses to treat conditions. It will describe some of the key advances made in material chemistry, and link these to the prevention of rejection by the host and a reduction in infectious disease, as well as reviewing some of the key pathogenic organisms associated with device infection, and the relative cost linked to device-associated infections.
Overview and changing epidemiology of Clostridium difficile infection
2014, Seminars in Colon and Rectal Surgery
There has been an increase in Clostridium difficile infection (CDI) incidence, severity, and mortality during the last decade. Although the elderly receiving antibiotic therapy are the most common group at risk for infection, CDI occurs in all age groups, and recent data indicate that CDI is emerging in groups that have been traditionally considered at low risk for infection. Additionally, approximately one-third of all CDI cases are now considered to be community associated in the U.S. New information is emerging on risk factors for an initial episode of CDI as well as recurrent disease. Increases in the burden of disease and severe outcomes related to CDI has been associated with the emergence of a new epidemic strain, restriction enzyme analysis BI, North American Pulsed-Field Type 1, and PCR Ribotype 027 (BI/NAP1/027) as well as other emerging strains. This article explores the changing epidemiology of CDI based on the latest available data as well as the recent developments in diagnosis and infection control.
Updated review of Clostridium difficile infection in elderly
2020, Revista Espanola de Geriatria y Gerontologia
La infección por Clostridium difficile es la causa más frecuente de diarrea nosocomial y presenta un incremento en su incidencia con la edad. Las manifestaciones clínicas, la tasa de resistencia, el riesgo de recurrencia y la respuesta a los diferentes tratamientos es diferente en la población adulta joven comparado con la población mayor.
El objetivo de esta revisión es actualizar la epidemiología, patogenia, diagnóstico, tratamiento y prevención de la infección por C. difficile en este grupo de edad, con la evidencia que hay hasta el momento actual.
Clostridium difficile infection is the most common cause of health care-associated diarrhoea, and its incidence increases with age. Clinical challenges, risk of resistance to treatment, risk of recurrence, and treatment responses are different in elderly.
The aim of this review is to discuss the updated epidemiology, pathophysiology, diagnosis, and therapeutic management of C. difficile infection in elderly with the available data.

View all citing articles on Scopus

View full text

Article preview

Journal of Hospital Infection

Abstract

Introduction

Section snippets

Location

Patients

Results

Discussion

Acknowledgements

References (10)

Hospital-acquired Clostridium difficile diarrhoea and herd immunity

Lancet

Hospital acquired Clostridium difficile diarrhoea

Lancet

Clostridium difficile in England and Wales—weeks 1-26/99

Commun Dis Rep CDR Wkly

Clostridium difficile infection: appendix

J Antimicrob Chemother

Prospective study of the risk of Clostridium difficile diarrhoea in elderly patients following treatment with cefotaxime or piperacillin–tazobactam

Aliment Pharmacol Therapeut

Cited by (89)

Reprint of: Overview and changing epidemiology of Clostridium difficile infection

Heterogeneity in application, design, and analysis characteristics was found for controlled before-after and interrupted time series studies included in Cochrane reviews

Good epidemiological practice: a narrative review of appropriate scientific methods to evaluate the impact of antimicrobial stewardship interventions

Introduction to biomaterials and medical device-associated infections

Overview and changing epidemiology of Clostridium difficile infection

Updated review of Clostridium difficile infection in elderly