Advertisement

Lack of improvement in antimicrobial prescribing after a diagnosis of Clostridium difficile and impact on recurrence

  • Richard L. Watson
    Affiliations
    Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA
    Search for articles by this author
  • Christopher J. Graber
    Correspondence
    Address correspondence to Christopher J. Graber, MD, MPH, David Geffen School of Medicine at UCLA, Infectious Diseases Section, VA Greater Los Angeles Healthcare System, 11301 Wilshire Blvd, 111-F, Los Angeles, CA 90073. (C.J. Graber).
    Affiliations
    Infectious Diseases Section, VA Greater Los Angeles Healthcare System, Los Angeles, CA

    Infectious Diseases Division, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA
    Search for articles by this author

      Background

      Antimicrobial use is one of the largest modifiable risk factors for development of Clostridium difficile infection (CDI). We sought to determine if a recent diagnosis of CDI affected the appropriateness of subsequent antimicrobial prescribing.

      Methods

      This study is a retrospective electronic chart review of the Greater Los Angeles Veterans Administration. Medication administration records were reviewed for all patients with new CDI from 2015-2016 to determine the appropriateness (drug choice, duration, and dosage) of all non-CDI antimicrobials prescribed within 90 days pre- and post-initial CDI (iCDI) positive testing.

      Results

      Of the 210 patients diagnosed with new-onset iCDI, 140 met inclusion criteria. Of antimicrobial courses prescribed, 40.6% of pre-iCDI were inappropriate compared with 43.1% of post-iCDI, demonstrating no difference in prescribing habits (P = .717). Thirty-three patients developed recurrent CDI (rCDI). After adjustment for other known risk factors, inappropriate antimicrobial use was associated with a significant increased risk of recurrence compared with appropriate use alone (odds ratio [OR], 6.19; 95% confidence interval [CI], 1.45-26.42). Antimicrobial use in general was associated with increased recurrence compared with no antimicrobial use post-iCDI (OR, 2.6; 95% CI, 1.16-5.84); however, after adjustment, it was no longer significant (OR, 2.13; 95% CI, 0.90-5.04).

      Conclusions

      The appropriateness of antimicrobial prescribing was not affected by the diagnosis of recent CDI. Inappropriate antimicrobial use after iCDI was associated with higher risk of rCDI.

      Key Words

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to American Journal of Infection Control
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Cohen S.H.
        • Gerding D.N.
        • Johnson S.
        • Kelly C.P.
        • Loo V.G.
        • McDonald L.C.
        • et al.
        Clinical practice guidelines for Clostridium difficile infection in adults: 2010 update by the Society for Healthcare Epidemiology of America (SHEA) and the Infectious Diseases Society of America (IDSA).
        Infect Control Hosp Epidemiol. 2010; 31: 431-455
        • Lessa F.C.
        • Mu Y.
        • Bamberg W.M.
        • Beldavs Z.G.
        • Dumyati G.K.
        • Dunn J.R.
        • et al.
        Burden of Clostridium difficile infection in the United States.
        N Engl J Med. 2015; 372: 825-834
        • McDonald L.C.
        • Gerding D.N.
        • Johnson S.
        • Bakken J.S.
        • Carroll K.C.
        • Coffin S.E.
        • et al.
        Clinical practice guidelines for Clostridium difficile infection in adults and children: 2017 update by the Infectious Diseases Society of America (IDSA) and Society for Healthcare Epidemiology of America (SHEA).
        Clin Infect Dis. 2018; 66: e1-48
        • Deshpande A.
        • Pasupuleti V.
        • Thota P.
        • Pant C.
        • Rolston D.D.
        • Sferra T.J.
        • et al.
        Community-associated Clostridium difficile infection and antibiotics: a meta-analysis.
        J Antimicrob Chemother. 2013; 68: 1951-1961
        • Chang H.T.
        • Krezolek D.
        • Johnson S.
        • Parada J.P.
        • Evans C.T.
        • Gerding D.N.
        Onset of symptoms and time to diagnosis of Clostridium difficile-associated disease following discharge from an acute care hospital.
        Infect Control Hosp Epidemiol. 2007; 28: 926-931
        • Stevens V.
        • Dumyati G.
        • Fine L.S.
        • Fisher S.G.
        • van Wijngaarden E.
        Cumulative antibiotic exposures over time and the risk of Clostridium difficile infection.
        Clin Infect Dis. 2011; 53: 42-48
        • McFarland L.V.
        • Surawicz C.M.
        • Stamm W.E.
        Risk factors for Clostridium difficile carriage and C. difficile-associated diarrhea in a cohort of hospitalized patients.
        J Infect Dis. 1990; 162: 678-684
        • Bignardi G.E.
        Risk factors for Clostridium difficile infection.
        J Hosp Infect. 1998; 40: 1-15
        • Davey P.
        • Brown E.
        • Charani E.
        • Fenelon L.
        • Gould I.M.
        • Holmes A.
        • et al.
        Interventions to improve antibiotic prescribing practices for hospital inpatients.
        Cochrane Database Syst Rev. 2013; (CD003543)
        • Climo M.W.
        • Israel D.S.
        • Wong E.S.
        • Williams D.
        • Coudron P.
        • Markowitz S.M.
        Hospital-wide restriction of clindamycin: effect on the incidence of Clostridium difficile-associated diarrhea and cost.
        Ann Intern Med. 1998; 128: 989-995
        • Carling P.
        • Fung T.
        • Killion A.
        • Terrin N.
        • Barza M.
        Favorable impact of a multidisciplinary antibiotic management program conducted during 7 years.
        Infect Control Hosp Epidemiol. 2003; 24: 699-706
        • Magill S.S.
        • Edwards J.R.
        • Beldavs Z.G.
        • Dumyati G.
        • Janelle S.J.
        • Kainer M.A.
        • et al.
        Prevalence of antimicrobial use in US acute care hospitals, May-September 2011.
        JAMA. 2014; 312: 1438-1446
        • van de Sande-Bruinsma N.
        • Grundmann H.
        • Verloo D.
        • Tiemersma E.
        • Monen J.
        • Goossens H.
        • et al.
        Antimicrobial drug use and resistance in Europe.
        Emerg Infect Dis. 2008; 14: 1722-1730
        • Fridkin S.
        • Baggs J.
        • Fagan R.
        • Magill S.
        • Pollack L.A.
        • Malpiedi P.
        • et al.
        Vital signs: improving antibiotic use among hospitalized patients.
        MMWR Morb Mortal Wkly Rep. 2014; 63: 194-200
        • Louie T.J.
        • Miller M.A.
        • Mullane K.M.
        • Weiss K.
        • Lentnek A.
        • Golan Y.
        • et al.
        Fidaxomicin versus vancomycin for Clostridium difficile infection.
        N Engl J Med. 2011; 364: 422-431
        • Barbut F.
        • Richard A.
        • Hamadi K.
        • Chomette V.
        • Burghoffer B.
        • Petit J.C.
        Epidemiology of recurrences or reinfections of Clostridium difficile-associated diarrhea.
        J Clin Microbiol. 2000; 38: 2386-2388
        • Johnson S.
        Recurrent Clostridium difficile infection: causality and therapeutic approaches.
        Int J Antimicrob Agents. 2009; 33: S33-S36
        • Deshpande A.
        • Pasupuleti V.
        • Thota P.
        • Pant C.
        • Rolston D.D.
        • Hernandez A.V.
        • et al.
        Risk factors for recurrent Clostridium difficile infection: a systematic review and meta-analysis.
        Infect Control Hosp Epidemiol. 2015; 36: 452-460
        • Drekonja D.M.
        • Amundson W.H.
        • Decarolis D.D.
        • Kuskowski M.A.
        • Lederle F.A.
        • Johnson J.R.
        Antimicrobial use and risk for recurrent Clostridium difficile infection.
        Am J Med. 2011; 124 (e1-7): 1081
        • Hu M.Y.
        • Katchar K.
        • Kyne L.
        • Maroo S.
        • Tummala S.
        • Dreisbach V.
        • et al.
        Prospective derivation and validation of a clinical prediction rule for recurrent Clostridium difficile infection.
        Gastroenterology. 2009; 136: 1206-1214
        • Fekety R.
        • McFarland L.V.
        • Surawicz C.M.
        • Greenberg R.N.
        • Elmer G.W.
        • Mulligan M.E.
        Recurrent Clostridium difficile diarrhea: characteristics of and risk factors for patients enrolled in a prospective, randomized, double-blinded trial.
        Clin Infect Dis. 1997; 24: 324-333
        • Linsky A.
        • Gupta K.
        • Lawler E.V.
        • Fonda J.R.
        • Hermos J.A.
        Proton pump inhibitors and risk for recurrent Clostridium difficile infection.
        Arch Intern Med. 2010; 170: 772-778
        • Pepin J.
        • Saheb N.
        • Coulombe M.A.
        • Alary M.E.
        • Corriveau M.P.
        • Authier S.
        • et al.
        Emergence of fluoroquinolones as the predominant risk factor for Clostridium difficile-associated diarrhea: a cohort study during an epidemic in Quebec.
        Clin Infect Dis. 2005; 41: 1254-1260
        • Shaughnessy M.K.
        • Amundson W.H.
        • Kuskowski M.A.
        • DeCarolis D.D.
        • Johnson J.R.
        • Drekonja D.M.
        Unnecessary antimicrobial use in patients with current or recent Clostridium difficile infection.
        Infect Control Hosp Epidemiol. 2013; 34: 109-116
        • Katz D.A.
        • Lynch M.E.
        • Littenberg B.
        Clinical prediction rules to optimize cytotoxin testing for Clostridium difficile in hospitalized patients with diarrhea.
        Am J Med. 1996; 100: 487-495
        • Fekety R.
        Guidelines for the diagnosis and management of Clostridium difficile-associated diarrhea and colitis. American College of Gastroenterology, Practice Parameters Committee.
        Am J Gastroenterol. 1997; 92: 739-750
        • Nair S.
        • Yadav D.
        • Corpuz M.
        • Pitchumoni C.S.
        Clostridium difficile colitis: factors influencing treatment failure and relapse–a prospective evaluation.
        Am J Gastroenterol. 1998; 93: 1873-1876
        • Spivak E.S.
        • Cosgrove S.E.
        • Srinivasan A.
        Measuring appropriate antimicrobial use: attempts at opening the black box.
        Clin Infect Dis. 2016; 63: 1639-1644
        • Polgreen P.M.
        • Chen Y.Y.
        • Cavanaugh J.E.
        • Ward M.
        • Coffman S.
        • Hornick D.B.
        • et al.
        An outbreak of severe Clostridium difficile-associated disease possibly related to inappropriate antimicrobial therapy for community-acquired pneumonia.
        Infect Control Hosp Epidemiol. 2007; 28: 212-214
        • McIsaac W.J.
        • Low D.E.
        • Biringer A.
        • Pimlott N.
        • Evans M.
        • Glazier R.
        The impact of empirical management of acute cystitis on unnecessary antibiotic use.
        Arch Intern Med. 2002; 162: 600-605
        • Hecker M.T.
        • Aron D.C.
        • Patel N.P.
        • Lehmann M.K.
        • Donskey C.J.
        Unnecessary use of antimicrobials in hospitalized patients: current patterns of misuse with an emphasis on the antianaerobic spectrum of activity.
        Arch Intern Med. 2003; 163: 972-978
        • Vanderweil S.G.
        • Tsai C.L.
        • Pelletier A.J.
        • Espinola J.A.
        • Sullivan A.F.
        • Blumenthal D.
        • et al.
        Inappropriate use of antibiotics for acute asthma in United States emergency departments.
        Acad Emerg Med. 2008; 15: 736-743
        • Cope M.
        • Cevallos M.E.
        • Cadle R.M.
        • Darouiche R.O.
        • Musher D.M.
        • Trautner B.W.
        Inappropriate treatment of catheter-associated asymptomatic bacteriuria in a tertiary care hospital.
        Clin Infect Dis. 2009; 48: 1182-1188
        • McDonald L.C.
        • Coignard B.
        • Dubberke E.
        • Song X.
        • Horan T.
        • Kutty P.K.
        • et al.
        Recommendations for surveillance of Clostridium difficile-associated disease.
        Infect Control Hosp Epidemiol. 2007; 28: 140-145