Antibiotic Overuse is a Major Risk Factor for <i>Clostridium difficile</i> Infection in Surgical Patients

Bernatz, James T.; Safdar, Nasia; Hetzel, Scott; Anderson, Paul A.

doi:10.1017/ice.2017.158

Cited by 26 publications

(18 citation statements)

References 9 publications

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“…Although in the outpatient clinics the majority of the prophylaxis was indicated for medical prophylaxis, still almost a quarter of prophylaxis were prescribed for post-surgical/intervention prophylaxis. In general, prolonged use of surgical prophylaxis has not been associated with better clinical outcome, but rather with emerging antimicrobial resistance and Clostridium difficile infections [21,22]. Therefore, prophylaxis that is continued after 24 h is in general considered inappropriate.…”

Section: Discussionmentioning

confidence: 99%

The appropriateness of antimicrobial use in the outpatient clinics of three hospitals in the Netherlands

Broek

Hest

Lettinga

et al. 2020

Antimicrob Resist Infect Control

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Objectives: Antimicrobial Stewardship Programs commonly have an in-hospital focus. Little is known about the quality of antimicrobial use in hospital outpatient clinics. We investigated the extent and appropriateness of antimicrobial prescriptions in the outpatient clinics of three hospitals. Methods: From June 2018 to January 2019, we performed ten point prevalence surveys in outpatient clinics of one university hospital and two large teaching hospitals. All prophylactic and therapeutic prescriptions were retrieved from the electronic medical records. Appropriateness was defined as being in accordance with guidelines. Furthermore, we investigated the extent to which the dose was adjusted to renal function and documentation of an antibiotic plan in the case notes. Results: We retrieved 720 prescriptions for antimicrobial drugs, of which 173 prescriptions (24%) were prophylactic. A guideline was present for 95% of prescriptions, of which the guideline non-adherence rate was 25.6% (n = 42/164) for prophylaxis and 43.1% (n = 224/520) for therapy. Of all inappropriate prescriptions (n = 266), inappropriate prescriptions for skin and soft tissue infections (n = 60/226) and amoxicillin-clavulanic acid (n = 67/266) made up the largest proportion. In only 13 of 138 patients with impaired or unknown renal function the dosage regimen was adjusted. Amoxicillin-clavulanic acid was the drug for which most often renal function was not taken into account. In 94.6% of prescriptions the antibiotic plan was documented. Conclusions: In hospital outpatient clinics, a substantial part of therapeutics were inappropriately prescribed. Amoxicillin-clavulanic acid was the most inappropriately prescribed drug, due to non-adherence to the guidelines and because dose adjustment to renal function was often not considered.

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Section: Discussionmentioning

confidence: 99%

The appropriateness of antimicrobial use in the outpatient clinics of three hospitals in the Netherlands

Broek

Hest

Lettinga

et al. 2020

Antimicrob Resist Infect Control

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“…In this study, however, 60% and 70% of the hip and knee cohorts, respectively, were considered high risk, calling into question the benefit of stratification. In addition to lack of evidence for benefit among spinal fusion patients, there is clear potential for harm with unnecessary use of antibiotics, including selection of antibiotic-resistant bacteria, 18 C. difficile infection, [19][20][21][22] and acute kidney injury. 20 In our study, the incidence of C. difficile did not differ by discharge antibiotic use; however, our study was not adequately powered for this comparison.…”

Section: Discussionmentioning

confidence: 99%

“…Unnecessary antibiotics may result in additional costs, adverse drug events, selection of antibiotic-resistant bacteria, 18 and the development of Clostridioides difficile infection. [19][20][21][22] The goals of our study were to determine the prevalence of postdischarge prophylactic antibiotic use and to identify patient characteristics, operative factors, and surgeon characteristics associated with use in a cohort of adults undergoing spinal fusion at 3 academically affiliated hospital study sites.…”

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confidence: 99%

Postdischarge antibiotic use for prophylaxis following spinal fusion

Warren

Nickel

Han

et al. 2020

Infect. Control Hosp. Epidemiol.

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Objective:Despite recommendations to discontinue prophylactic antibiotics after incision closure or <24 hours after surgery, prophylactic antibiotics are continued after discharge by some clinicians. The objective of this study was to determine the prevalence and factors associated with postdischarge prophylactic antibiotic use after spinal fusion.Design:Multicenter retrospective cohort study.Patients:This study included patients aged ≥18 years undergoing spinal fusion or refusion between July 2011 and June 2015 at 3 sites. Patients with an infection during the surgical admission were excluded.Methods:Prophylactic antibiotics were identified at discharge. Factors associated with postdischarge prophylactic antibiotic use were identified using hierarchical generalized linear models.Results:In total, 8,652 spinal fusion admissions were included. Antibiotics were prescribed at discharge in 289 admissions (3.3%). The most commonly prescribed antibiotics were trimethoprim/sulfamethoxazole (22.1%), cephalexin (18.8%), and ciprofloxacin (17.1%). Adjusted for study site, significant factors associated with prophylactic discharge antibiotics included American Society of Anesthesiologists (ASA) class ≥3 (odds ratio [OR], 1.31; 95% CI, 1.00–1.70), lymphoma (OR, 2.57; 95% CI, 1.11–5.98), solid tumor (OR, 3.63; 95% CI, 1.62–8.14), morbid obesity (OR, 1.64; 95% CI, 1.09–2.47), paralysis (OR, 2.38; 95% CI, 1.30–4.37), hematoma/seroma (OR, 2.93; 95% CI, 1.17–7.33), thoracic surgery (OR, 1.39; 95% CI, 1.01–1.93), longer length of stay, and intraoperative antibiotics.Conclusions:Postdischarge prophylactic antibiotics were uncommon after spinal fusion. Patient and perioperative factors were associated with continuation of prophylactic antibiotics after hospital discharge.

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“…Recent published data indicate that treatment with proton pump inhibitors or prolonged perioperative antibiotherapy (previously regarded as safe or non-related) might be substantial contributors to outbreaks of virulent strains [7,10]. There are still debates regarding mechanical bowel preparation in association with prophylactic intravenous or oral antibiotherapy as a risk factor for developing Clostridium difficile infection in patients undergoing colorectal surgery [17,18].…”

Section: Discussionmentioning

confidence: 99%

“…While age, antibiotic (especially combined antibiotics) and proton pump inhibitor use in the 10 days prior to surgery, previous hospitalization, and decreased immunity are firmly established as favorable factors in developing postoperative C. difficile colitis, the role of bowel preparation remains controversial [5,6]. Colorectal surgery, in particular, is seldom cited as an independent risk factor in up to 21% of patients who had undergone colectomies and 29% of patients who underwent a surgical procedure for bowel obstruction, but the complexity of the surgery itself, as represented by operative time and blood loss, did not correlate with increased odds of CDI [7].…”

Section: Introductionmentioning

confidence: 99%

Clostridium difficile Infection and Colorectal Surgery: Is There Any Risk?

et al. 2019

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Background and objectives: Clostridium difficile infection (CDI) is an important healthcare-associated infection, with important consequences both from a medical and financial point of view, but its correlation with anastomotic leaks after colorectal surgeries is scarcely reported in the literature. Materials and Methods: We conducted a retrospective study looking for patients who underwent open or laparoscopic surgery for colorectal cancers between January 2012 and December 2017, excluding emergency surgeries for complicated colorectal tumors. We also examined patient history for risk factors for CDI such as age, sex, comorbidities, and clinical findings at admission or during hospital stay as well as tumor characteristics. Results: A total of 360 patients were included in the study, out of which 320 underwent surgeries that included anastomoses. There were 19 cases of anastomotic leaks, out of which 13 patients were diagnosed with CDI, with a statistic significance for association between CDI and anastomotic leakage (p < 0.0001). Most patients who developed both CDI and anastomotic leaks had left-sided resections or a type of rectal resection, while none of the patients with right-sided resections had this association, but with no statistical significance possibly due to the limited number of cases. Conclusions: CDI is a relevant risk factor and should be taken into consideration when trying to prevent anastomotic leaks in patients undergoing gastrointestinal surgery for colon or rectal cancer. Thorough assessment of risk factors at admission should be mandatory in order to adequately prepare the patient and plan an optimal course of treatment. Further studies are needed to confirm our findings and a multidisciplinary approach, with a team which should always include the surgeon, is mandatory when it comes to CDI prevention.

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Antibiotic Overuse is a Major Risk Factor for Clostridium difficile Infection in Surgical Patients

Cited by 26 publications

References 9 publications

The appropriateness of antimicrobial use in the outpatient clinics of three hospitals in the Netherlands

The appropriateness of antimicrobial use in the outpatient clinics of three hospitals in the Netherlands

Postdischarge antibiotic use for prophylaxis following spinal fusion

Clostridium difficile Infection and Colorectal Surgery: Is There Any Risk?

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