Effects of fluoroquinolone restriction (from 2007 to 2012) on Clostridium difficile infections: interrupted time-series analysis

Sarma, Jogesh; Marshall, Bryan E.; Cleeve, V.; Tate, David F.; Oswald, T; Woolfrey, Steven G.

doi:10.1016/j.jhin.2015.05.013

Cited by 48 publications

(33 citation statements)

References 20 publications

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“…Finally, the much smaller population size meant that these univariate cross-correlations were estimated imprecisely compared with those for England as a whole. Our study therefore clarifies the issue of whether fluoroquinolone or cephalosporin restriction alone or in combination is key to C difficile infection control 34, 35, 36. However, changes in dominant genotypes over time have been reported in a single centre in the absence of antimicrobial restriction policies 37 .…”

Section: Discussionsupporting

confidence: 52%

Effects of control interventions on Clostridium difficile infection in England: an observational study

Dingle

Didelot

Quan

et al. 2017

The Lancet Infectious Diseases

287

226

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SummaryBackgroundThe control of Clostridium difficile infections is an international clinical challenge. The incidence of C difficile in England declined by roughly 80% after 2006, following the implementation of national control policies; we tested two hypotheses to investigate their role in this decline. First, if C difficile infection declines in England were driven by reductions in use of particular antibiotics, then incidence of C difficile infections caused by resistant isolates should decline faster than that caused by susceptible isolates across multiple genotypes. Second, if C difficile infection declines were driven by improvements in hospital infection control, then transmitted (secondary) cases should decline regardless of susceptibility.MethodsRegional (Oxfordshire and Leeds, UK) and national data for the incidence of C difficile infections and antimicrobial prescribing data (1998–2014) were combined with whole genome sequences from 4045 national and international C difficile isolates. Genotype (multilocus sequence type) and fluoroquinolone susceptibility were determined from whole genome sequences. The incidence of C difficile infections caused by fluoroquinolone-resistant and fluoroquinolone-susceptible isolates was estimated with negative-binomial regression, overall and per genotype. Selection and transmission were investigated with phylogenetic analyses.FindingsNational fluoroquinolone and cephalosporin prescribing correlated highly with incidence of C difficile infections (cross-correlations >0·88), by contrast with total antibiotic prescribing (cross-correlations <0·59). Regionally, C difficile decline was driven by elimination of fluoroquinolone-resistant isolates (approximately 67% of Oxfordshire infections in September, 2006, falling to approximately 3% in February, 2013; annual incidence rate ratio 0·52, 95% CI 0·48–0·56 vs fluoroquinolone-susceptible isolates: 1·02, 0·97–1·08). C difficile infections caused by fluoroquinolone-resistant isolates declined in four distinct genotypes (p<0·01). The regions of phylogenies containing fluoroquinolone-resistant isolates were short-branched and geographically structured, consistent with selection and rapid transmission. The importance of fluoroquinolone restriction over infection control was shown by significant declines in inferred secondary (transmitted) cases caused by fluoroquinolone-resistant isolates with or without hospital contact (p<0·0001) versus no change in either group of cases caused by fluoroquinolone-susceptible isolates (p>0·2).InterpretationRestricting fluoroquinolone prescribing appears to explain the decline in incidence of C difficile infections, above other measures, in Oxfordshire and Leeds, England. Antimicrobial stewardship should be a central component of C difficile infection control programmes.FundingUK Clinical Research Collaboration (Medical Research Council, Wellcome Trust, National Institute for Health Research); NIHR Oxford Biomedical Research Centre; NIHR Health Protection Research Unit on Healthcare Associated Inf...

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Section: Discussionsupporting

confidence: 52%

Effects of control interventions on Clostridium difficile infection in England: an observational study

Dingle

Didelot

Quan

et al. 2017

The Lancet Infectious Diseases

287

226

View full text Add to dashboard Cite

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“…Single-center studies have shown decreased CDI rates postimplementation of moxifloxacin education and restriction ([59 Ϯ 3] versus [32 Ϯ 3] CDI cases/month; P ϭ 0.0044) (11). A two-center, community hospital study assessed the impact of fluoroquinolone (levofloxacin and ciprofloxacin) restriction (phase 1) and removal from ward stock (phase 2) on CDI with similar results (12). Our present study provides additional confirmation on a health care system level demonstrating that a decrease in moxifloxacin use can lead to a reduction in CDI rate.…”

Section: Discussionmentioning

confidence: 87%

“…In addition, there is speculation that the incidence of CDI may be higher with antianaerobic fluoroquinolones, such as moxifloxacin, due to a potential for greater disruption in normal flora. A reduction in fluoroquinolone use may also lead to a reduction in CDI (10)(11)(12). Antimicrobial stewardship strategies have been shown to reduce fluoroquinolone utilization by 30 to 70% (13)(14)(15)(16)(17).…”

mentioning

confidence: 99%

Effect of a Health Care System Respiratory Fluoroquinolone Restriction Program To Alter Utilization and Impact Rates of Clostridium difficile Infection

Shea

Hobbs

Jaso

et al. 2017

Antimicrob Agents Chemother

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Fluoroquinolones are one of the most commonly prescribed antibiotic classes in the United States despite their association with adverse consequences, including Clostridium difficile infection (CDI). We sought to evaluate the impact of a health care system antimicrobial stewardship-initiated respiratory fluoroquinolone restriction program on utilization, appropriateness of quinolone-based therapy based on institutional guidelines, and CDI rates. After implementation, respiratory fluoroquinolone utilization decreased from a monthly mean and standard deviation (SD) of 41.0 (SD ϭ 4.4) days of therapy (DOT) per 1,000 patient days (PD) preintervention to 21.5 (SD ϭ 6.4) DOT/1,000 PD and 4.8 (SD ϭ 3.6) DOT/1,000 PD posteducation and postrestriction, respectively. Using segmented regression analysis, both education (14.5 DOT/1,000 PD per month decrease; P ϭ 0.023) and restriction (24.5 DOT/1,000 PD per month decrease; P Ͻ 0.0001) were associated with decreased utilization. In addition, the CDI rates decreased significantly (P ϭ 0.044) from preintervention using education (3.43 cases/10,000 PD) and restriction (2.2 cases/10,000 PD). Mean monthly CDI cases/10,000 PD decreased from 4.0 (SD ϭ 2.1) preintervention to 2.2 (SD ϭ 1

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“…They have successfully restricted the use of cephalosporins and, subsequently, of fluoroquinolones. with provided structured information on CDI, was associated with an immediate decrease of CDI rates in this large community teaching hospital [72].…”

Section: Clostridium Difficile -A Comprehensive Overviewmentioning

confidence: 95%

Clostridium difficile Infection Diagnosis by Biological Molecular Methods

Iancu¹,

Cârlan²,

Ursu³

2017

Clostridium Difficile - A Comprehensive Overview

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In the past 15 years, the incidence of Clostridium difficile infection has emerged especially because of the new highly virulent strains. The classical diagnosis methods used to diagnose C. difficile infection take time and the enzyme immunoassay (EIA) test has demonstrated the lack of sensitivity. Even though new modern molecular methods have become available, the diagnosis of C. difficile in patients or healthy carriers remains a big challenge for both clinicians and laboratory staff. In the present chapter, we will list the main genotyping methods, stressing their advantages and disadvantages, as well. A brief presentation of the most useful kit (principle, sensitivity, specificity, benefits and disadvantages) to assess the impact of molecular methods in comparison with classical methods will offer support for future research in the present context of an increasing prevalence of C. difficile infection that represents worldwide, a real public health problem. To improve the patients' quality of life, to limit hospital transmission, and to save money, we have tried to identify the best diagnosis algorithm as tool in C. difficile diagnosis and surveillance. This algorithm may differ depending on the capacities of the laboratories and on the socioeconomic level of the countries in question.

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Effects of fluoroquinolone restriction (from 2007 to 2012) on Clostridium difficile infections: interrupted time-series analysis

Cited by 48 publications

References 20 publications

Effects of control interventions on Clostridium difficile infection in England: an observational study

Effects of control interventions on Clostridium difficile infection in England: an observational study

Effect of a Health Care System Respiratory Fluoroquinolone Restriction Program To Alter Utilization and Impact Rates of Clostridium difficile Infection

Clostridium difficile Infection Diagnosis by Biological Molecular Methods

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