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Increased incidence of Clostridium difficile-associated diarrhea following decreased restriction of antibiotic use
1Clinical Pharmacy Service, Department of Veterans Affairs Medical Center, Long Beach, California 90822, USA.
Abstract:
Removal of antimicrobial agents from formulary restriction status at our center was followed by an increase in the incidence of Clostridium difficile-associated diarrhea. The mean monthly incidence of C. difficile diarrhea for the 12-month period before institution of decreased restriction of antibiotic use was 3.4 infections per 1,000 admissions and rose to 6.2 infections per 1,000 admissions during the following 4-month period (P < .05). Patients who developed disease before and after decreased restriction of antibiotics were similar in terms of the mean number of antimicrobial agents administered and mean duration of therapy. The most commonly administered agents whose use preceded the onset of disease were cefazolin, trimethoprim-sulfamethoxazole, ampicillin, ticarcillin/clavulanate, and gentamicin (the latter drug was always used in combination with other agents). Immunoblot typing indicated that there was no association between C. difficile strains and administration of specific agents. There was no coincidental epidemic to account for the increased incidence of infection. The increased incidence of C. difficile disease is a potential problem that may occur following removal of extended-spectrum antimicrobial agents from formulary restriction status.
Insights
Removing antimicrobial restrictions led to a rise in Clostridium difficile infections. This highlights the need for careful antibiotic stewardship to prevent C. difficile-associated diarrhea outbreaks.
Area of Science:
- Infectious Diseases
- Hospital Epidemiology
- Antimicrobial Stewardship
Background:
- Antimicrobial agents are crucial for treating bacterial infections.
- Formulary restrictions aim to optimize antimicrobial use and prevent resistance.
- Clostridium difficile-associated diarrhea (CDAD) is a significant healthcare-associated infection.
Purpose of the Study:
- To investigate the impact of removing formulary restrictions on antimicrobial agents.
- To assess the subsequent changes in the incidence of Clostridium difficile-associated diarrhea (CDAD).
Main Methods:
- Retrospective analysis of CDAD incidence before and after policy change.
- Comparison of patient demographics and antimicrobial exposure between groups.
- Analysis of antimicrobial agents commonly used prior to CDAD onset.
- Strain typing of Clostridium difficile isolates.
Main Results:
- Mean monthly incidence of CDAD increased from 3.4 to 6.2 per 1,000 admissions post-restriction removal (P < .05).
- Patients with CDAD before and after policy change had similar antimicrobial exposure (number of agents, duration).
- Commonly preceding agents included cefazolin, trimethoprim-sulfamethoxazole, ampicillin, ticarcillin/clavulanate, and gentamicin.
- No association found between specific C. difficile strains and antimicrobial administration; no concurrent epidemic identified.
Conclusions:
- Removal of antimicrobial formulary restrictions was associated with a significant increase in CDAD incidence.
- This suggests that reduced antimicrobial stewardship may contribute to CDAD outbreaks.
- Careful consideration and monitoring are necessary when revising antimicrobial restriction policies.