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Empirical Antimicrobial Prescriptions in Patients with Clostridium difficile Infection at Hospital Admission and Impact on Clinical Outcome

Published online by Cambridge University Press:  02 January 2015

Aurora Pop-Vicas*
Affiliation:
Memorial Hospital of Rhode Island, Pawtucket, Rhode Island Warren Alpert Medical School of Brown University, Providence, Rhode Island
Eman Shaban
Affiliation:
Memorial Hospital of Rhode Island, Pawtucket, Rhode Island Warren Alpert Medical School of Brown University, Providence, Rhode Island
Cecile Letourneau
Affiliation:
Memorial Hospital of Rhode Island, Pawtucket, Rhode Island
Angel Pechie
Affiliation:
Memorial Hospital of Rhode Island, Pawtucket, Rhode Island
*
Division of Infectious Diseases, Memorial Hospital of Rhode Island, 111 Brewster Street, Pawtucket, RI 02860 ([email protected])

Abstract

Objective.

To determine, among patients with Clostridium difficile infection (CDI) at hospital admission, the impact of concurrent use of systemic, non-CDI-related antimicrobials on clinical outcomes and the risk factors associated with unnecessary antimicrobial prescribing.

Design.

Retrospective cohort study.

Setting.

University-affiliated community hospital.

Methods.

We reviewed computerized medical records for all patients with CDI at hospital admission during a 24-month period (January 1, 2008, through December 31, 2009). Colectomy, discharge to hospice, and in-hospital mortality were considered to be adverse outcomes. Antimicrobial use was considered unnecessary in the absence of physical signs and laboratory or radiological findings suggestive of an infection other than CDI or in the absence of antimicrobial activity against the organism(s) recovered from clinical cultures.

Results.

Among the 94 patients with CDI at hospital admission, 62% received at least one non-CDI-related antimicrobial during their hospitalization for CDI. Severe complicated CDI (odds ratio [OR], 7.1 [95% confidence interval {CI}, 1.8–28.5]; P = .005), duration of non-CDI-related antimicrobial exposure (OR, 1.2 [95% CI, 1.03–1.36]; P = .016), and age (OR, 1.1 [95% CI, 1.0–1.1]; P = .043) were independent risk factors for adverse clinical outcomes. One-third of the patients received unnecessary antimicrobial therapy. Sepsis at hospital admission (OR, 5.3 [95% CI, 1.8–15.8]; P = .003) and clinical suspicion of urinary tract infection (OR, 9.7 [95% CI, 2.9–32.3]; P< .001) were independently associated with unnecessary antimicrobial prescriptions.

Conclusions.

Empirical use of non-CDI-related antimicrobials was common. Prolonged exposure to non-CDI-related antimicrobials was associated with adverse clinical outcomes, including increased in-hospital mortality. Minimizing non-CDI-related antimicrobial exposure in patients with CDI seems warranted.

Type
Original Articles
Copyright
Copyright © The Society for Healthcare Epidemiology of America 2012

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References

1.Loo, VG, Poirier, L, Miller, MA, et al.A predominantly clonal multi-institutional outbreak of Clostridium difficile-associated diarrhea with high morbidity and mortality. N Engl J Med 2005;353(23):24422449.CrossRefGoogle ScholarPubMed
2.McDonald, LC, Killgore, GE, Thompson, A, et al.An epidemic, toxin gene-variant strain of Clostridium difficile. N Engl J Med 2005;353(23):24332441.CrossRefGoogle ScholarPubMed
3.McDonald, LC, Owings, M, Jernigan, DB. Clostridium difficile infection in patients discharged from US short-stay hospitals, 1996–2003. Emerg Infect Dis 2006;12(3):409415.CrossRefGoogle ScholarPubMed
4.Pepin, J, Valiquette, L, Alary, ME, et al.Clostridium difficile-associated diarrhea in a region of Quebec from 1991 to 2003: a changing pattern of disease severity. CMAJ 2004;171(5):466472.CrossRefGoogle Scholar
5.Pepin, J, Valiquette, L, Cossette, B. Mortality attributable to nosocomial Clostridium difficile-associated disease during an epidemic caused by a hypervirulent strain in Quebec. CMAJ 2005;173(9):10371042.CrossRefGoogle ScholarPubMed
6.Simor, AE. Diagnosis, management, and prevention of Clostridium difficile infection in long-term care facilities: a review. J Am Geriatr Soc 58(8):15561564.CrossRefGoogle Scholar
7.Simor, AE, Bradley, SF, Strausbaugh, LJ, Crossley, K, Nicolle, LE. Clostridium difficile in long-term-care facilities for the elderly. Infect Control Hosp Epidemiol 2002;23(11):696703.CrossRefGoogle ScholarPubMed
8.Walker, KJ, Gilliland, SS, Vance-Bryan, K, et al.Clostridium difficile colonization in residents of long-term care facilities: prevalence and risk factors. J Am Geriatr Soc 1993;41(9):940946.CrossRefGoogle ScholarPubMed
9.Cohen, SH, Gerding, DN, Johnson, S, 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 31(5):431455.CrossRefGoogle Scholar
10.Annane, D, Bellissant, E, Cavaillon, JM. Septic shock. Lancet 2005;365(9453):6378.CrossRefGoogle ScholarPubMed
11.Stamm, WE. Measurement of pyuria and its relation to bacteriuria. Am J Med 1983;75(1B):5358.CrossRefGoogle ScholarPubMed
12.Wilson, ML, Gaido, L. Laboratory diagnosis of urinary tract infections in adult patients. Clin Infect Dis 2004;38(8):11501158.CrossRefGoogle ScholarPubMed
13.Charlson, ME, Pompei, P, Ales, KL, MacKenzie, CR. A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chronic Dis 1987;40(5):373383.CrossRefGoogle ScholarPubMed
14.Cosgrove, SE, Patel, A, Song, X, et al.Impact of different methods of feedback to clinicians after postprescription antimicrobial review based on the Centers For Disease Control and Prevention's 12 Steps to Prevent Antimicrobial Resistance Among Hospitalized Adults. Infect Control Hosp Epidemiol 2007;28(6):641646.CrossRefGoogle ScholarPubMed
15.Hecker, MT, Aron, DC, Patel, NP, Lehmann, MK, Donskey, CJ. 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(8):972978.CrossRefGoogle ScholarPubMed
16.Werner, NL, Hecker, MT, Sethi, AK, Donskey, CJ. Unnecessary use of fluoroquinolone antibiotics in hospitalized patients. BMC Infect Dis 11:187.CrossRefGoogle Scholar
17.Gaieski, DF, Mikkelsen, ME, Band, RA, et al.Impact of time to antibiotics on survival in patients with severe sepsis or septic shock in whom early goal-directed therapy was initiated in the emergency department. Crit Care Med 38(4):10451053.CrossRefGoogle Scholar
18.Nicolle, LE. Asymptomatic bacteriuria in the elderly. Infect Dis Clin North Am 1997;11(3):647662.CrossRefGoogle ScholarPubMed
19.Woodford, HJ, George, J. Diagnosis and management of urinary tract infection in hospitalized older people. J Am Geriatr Soc 2009;57(1):107114.CrossRefGoogle ScholarPubMed
20.Rotjanapan, P, Dosa, D, Thomas, KS. Potentially inappropriate treatment of urinary tract infections in two Rhode Island nursing homes. Arch Intern Med 171(5):438443.Google Scholar
21.Lautenbach, E, Marsicano, R, Tolomeo, P, Heard, M, Serrano, S, Stiereitz, DD. Epidemiology of antimicrobial resistance among gram-negative organisms recovered from patients in a multistate network of long-term care facilities. Infect Control Hosp Epidemiol 2009;30(8):790793.CrossRefGoogle Scholar
22.Smith, PW, Seip, CW, Schaefer, SC, Bell-Dixon, C. Microbiologic survey of long-term care facilities. Am J Infect Control 2000;28(1):813.CrossRefGoogle ScholarPubMed
23.Pop-Vicas, A, Mitchell, SL, Kandel, R, Schreiber, R, D'Agata, EM. Influx of multidrug-resistant, gram-negative bacteria in the hospital setting and the role of elderly patients with bacterial bloodstream infection. Infect Control Hosp Epidemiol 2009;30(4):325331.CrossRefGoogle ScholarPubMed
24.McGowan, JE Jr. Antimicrobial resistance in hospital organisms and its relation to antibiotic use. Rev Infect Dis 1983;5(6):10331048.CrossRefGoogle ScholarPubMed
25.Henrich, TJ, Krakower, D, Bitton, A, Yokoe, DS. Clinical risk factors for severe Clostridium difficile-associated disease. Emerg Infect Dis 2009;15(3):415422.CrossRefGoogle ScholarPubMed
26.Gujja, D, Friedenberg, FK. Predictors of serious complications due to Clostridium difficile infection. Aliment Pharmacol Ther 2009;29(6):635642.CrossRefGoogle ScholarPubMed
27.Garey, KW, Sethi, S, Yadav, Y, DuPont, HL. Meta-analysis to assess risk factors for recurrent Clostridium difficile infection. J Hosp Infect 2008;70(4):298304.CrossRefGoogle ScholarPubMed
28.Nair, S, Yadav, D, Corpuz, M, Pitchumoni, CS. Clostridium difficile colitis: factors influencing treatment failure and relapse-a prospective evaluation. Am J Gastroenterol 1998;93(10):18731876.CrossRefGoogle ScholarPubMed