Impact of a Reduction in the Use of High-Risk Antibiotics on the Course of an Epidemic of Clostridium difficile-Associated Disease Caused by the Hypervirulent NAP1/027 Strain

Valiquette, Louis; Cossette, Benoȋt; Garant, Marie-Pierre; Diab, Hassan Mahmoud; Pépin, Jacques

doi:10.1086/519258

Cited by 298 publications

(184 citation statements)

References 36 publications

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“…Importantly, it has been emphasized that an approach combining optimal infection control practices with antimicrobial stewardship is required in order to interrupt transmission and successfully control CDI outbreaks. 25,42 ' 43 The current CDI outbreak ended after the implementation of a series of controlling measures that targeted high-risk antibiotic agents (ie, restricting the use of fluoroquinolones), infection control practices, and environmental hygiene; this was achieved through the extended ICT and HSIT ensuring that ward staff understood their role in controlling the outbreak. The implementation of the infection control and environmental hygiene measures was uniform among the affected hospitals, with the exception of the isolation ward, which was established only in Antrim Area Hospital.…”

Section: Resultsmentioning

confidence: 99%

Multihospital Outbreak ofClostridium difficileRibotype 027 Infection: Epidemiology and Analysis of Control Measures

Aldeyab

Devine

Flanagan

et al. 2011

Infect. Control Hosp. Epidemiol.

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Objective.To report a large outbreak ofClostridium difficileinfection (CDI; ribotype 027) between June 2007 and August 2008, describe infection control measures, and evaluate the impact of restricting the use of fluoroquinolones in controlling the outbreak.Design.Outbreak investigation in 3 acute care hospitals of the Northern Health and Social Care Trust in Northern Ireland.Interventions.Implementation of a series of CDI control measures that targeted high-risk antibiotic agents (ie, restriction of fluoroquinolones), infection control practices, and environmental hygiene.Results.A total of 318 cases of CDI were identified during the outbreak, which was the result of the interaction betweenC. difficileribotype 027 being introduced into the affected hospitals for the first time and other predisposing risk factors (ranging from host factors to suboptimal compliance with antibiotic guidelines and infection control policies). The 30-day all-cause mortality rate was 24.5%; however, CDI was the attributable cause of death for only 2.5% of the infected patients. Time series analysis showed that restricting the use of fluoroquinolones was associated with a significant reduction in the incidence of CDI (coefficient, —0.054; lag time, 4 months;P= .003).Conclusion.These findings provide additional evidence to support the value of antimicrobial stewardship as an essential element of multifaceted interventions to control CDI outbreaks. The present CDI outbreak was ended following the implementation of an action plan improving communication, antibiotic stewardship, infection control practices, environmental hygiene, and surveillance.

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Section: Resultsmentioning

confidence: 99%

Multihospital Outbreak ofClostridium difficileRibotype 027 Infection: Epidemiology and Analysis of Control Measures

Aldeyab

Devine

Flanagan

et al. 2011

Infect. Control Hosp. Epidemiol.

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“…Improved infection control practices, combined with voluntary antibiotic control programmes, have recently been credited for large reductions in CDI rates in Quebec. 27 Therefore, it is unclear that action to curb PPI use will lead to an important reduction in CDI rates, especially in endemic settings. Perspective on the magnitude of this risk can be gained by comparison of number needed to harm (NNH) to cause one adverse effect vs. number needed to treat (NNT) to prevent one disease event.…”

Section: Discussionmentioning

confidence: 99%

Proton pump inhibitors increase significantly the risk of Clostridium difficile infection in a low‐endemicity, non‐outbreak hospital setting

Dalton

Lye-Maccannell

Henderson

et al. 2009

Aliment Pharmacol Ther

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“…In one study, metronidazole was not eff ective in eliminating carriage, and while vancomycin initially cleared the organism from stools, the rate of re-colonization was high at follow up 2 months later ( 169 ) Numerous studies have shown that restriction of the most common off ending antimicrobials is eff ective in CDI prevention ( 171 -173 ). In one study, an antimicrobial stewardship program contributed to a 60 % decrease in CDI incidence during an epidemic ( 173 ). During an epidemic, active monitoring of CDI, as is done for vancomycin-resistant enterococcal infections, allows identifi cation of alarming trends and the chance for relatively early interventions.…”

Section: Management Of CDI and Co-morbid Conditionsmentioning

confidence: 99%

Guidelines for Diagnosis, Treatment, and Prevention of Clostridium difficile Infections

Surawicz

Brandt

Binion

et al. 2013

American Journal of Gastroenterology

1,478

1,408

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Clostridium diffi cile infection (CDI) is a leading cause of hospital-associated gastrointestinal illness and places a high burden on our health-care system. Patients with CDI typically have extended lengths-of-stay in hospitals, and CDI is a frequent cause of large hospital outbreaks of disease. This guideline provides recommendations for the diagnosis and management of patients with CDI as well as for the prevention and control of outbreaks while supplementing previously published guidelines. New molecular diagnostic stool tests will likely replace current enzyme immunoassay tests. We suggest treatment of patients be stratifi ed depending on whether they have mild-to-moderate, severe, or complicated disease. Therapy with metronidazole remains the choice for mildto-moderate disease but may not be adequate for patients with severe or complicated disease. We propose a classifi cation of disease severity to guide therapy that is useful for clinicians. We review current treatment options for patients with recurrent CDI and recommendations for the control and prevention of outbreaks of CDI. Am J Gastroenterol 2013; 108:478-498; doi: 10.1038/ajg.2013 12. In patients in whom oral antibiotics cannot reach a segment of the colon, such as with Hartman's pouch, ileostomy, or colon diversion, vancomycin therapy delivered via enema should be added to treatments above until the patient improves. (Conditional recommendation, low-quality evidence)13. The use of anti-peristaltic agents to control diarrhea from confi rmed or suspected CDI should be limited or avoided, as they may obscure symptoms and precipitate complicated disease. Use of anti-peristaltic agents in the setting of CDI must always be accompanied by medical therapy for CDI. (Strong recommendation, low-quality evidence) Management of severe and complicated CDI14. Supportive care should be delivered to all patients and includes intravenous fl uid resuscitation, electrolyte replacement, and pharmacological venous thromboembolism prophylaxis. Furthermore, in the absence of ileus or signifi cant abdominal distention, oral or enteral feeding should be continued. 17. Vancomycin delivered orally (500 mg four times per day) and per rectum (500 mg in a volume of 500 ml four times a day) plus intravenous metronidazole (500 mg three times a day) is the treatment of choice for patients with complicated CDI with ileus or toxic colon and / or signifi cant abdominal distention. (Strong recommendation, low-quality evidence)18. Surgical consult should be obtained in all patients with complicated CDI. Surgical therapy should be considered in patients with any one of the following attributed to CDI: hypotension requiring vasopressor therapy; clinical signs of sepsis and organ dysfunction (renal and pulmonary); mental status changes; white blood cell count ≥ 50,000 cells / μ l, lactate ≥ 5 mmol / l; or failure to improve on medical therapy after 5 days. (Strong recommendation, moderate-quality evidence) Management of recurrent CDI (RCDI)19. The fi rst recurrence of CDI can be treated ...

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Impact of a Reduction in the Use of High-Risk Antibiotics on the Course of an Epidemic of Clostridium difficile-Associated Disease Caused by the Hypervirulent NAP1/027 Strain

Cited by 298 publications

References 36 publications

Multihospital Outbreak ofClostridium difficileRibotype 027 Infection: Epidemiology and Analysis of Control Measures

Multihospital Outbreak ofClostridium difficileRibotype 027 Infection: Epidemiology and Analysis of Control Measures

Proton pump inhibitors increase significantly the risk of Clostridium difficile infection in a low‐endemicity, non‐outbreak hospital setting

Guidelines for Diagnosis, Treatment, and Prevention of Clostridium difficile Infections

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