Complete Restriction of Fluoroquinolone Use to Control an Outbreak of<i>Clostridium difficile</i>Infection at a Community Hospital

Kallen, Alexander J.; Thompson, Angela; Ristaino, Polly; Chapman, Leigh; Nicholson, Ainsley C.; Sim, Bich Thuy; Lessa, Fernanda C.; Sharapov, Umid M.; Fadden, Elaine; Boehler, Richard; Gould, Carolyn V.; Limbago, Brandi; Blythe, David; McDonald, L. Clifford

doi:10.1086/595694

Cited by 80 publications

(69 citation statements)

References 31 publications

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“…Restricting the use of fluoroquinolones was associated with a significant reduction in the incidence of CDI, confirming fluoroquinolones as high-risk agents. 25,39 In addition, the analysis showed that the use of amoxicillin-clavulanic acid and macrolides was also positively correlated with the incidence of CDI. However, second-and third-generation cephalosporins did not appear as significant variables in the model, since their usage rate was already very low within the Trust.…”

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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“…The ability to identify rapidly a cluster of patients in a hospital that is infected with the 027/NAP1/BI strain could be the key to implementing infection control efforts to halt transmission in the hospital, including restriction of fluoroquinolones (15,20,35). The 027/NAP1/BI isolates have the potential to produce high levels of spores and require enhanced environmental cleaning efforts for eradication (1,35).…”

Section: Discussionmentioning

confidence: 99%

“…There were no significant differences between the sensitivities, specificities, or positive or negative predictive values of the results obtained with the Xpert C. difficile test and the results of PCR-ribotyping, REA, or PFGE (P Ͼ 0.05 for all comparisons) ( Table 4). The presumptive (17) 078 (14); 027 NAP7 (6); NAP1 CF (10) 017 (10) NAP9 (9) DH (19) 106 (14); 002, 046, 053 NAP11 (12) G (20) 002 (17); 104 Undefined types only J (22) 001 (7); 046, 056 NAP2 (7) K (8) 053 (6) Undefined types only Y (40) 020 (8) (11) 017 (11) CF (9); BK, Y NAP11 (24) 106 (13); 104 DH (12); G NAP12 (7) 087 (4) identification of the 027/NAP1/BI strain using the Xpert cartridge was available within 45 min of initiating the testing of the stool sample. Distribution of known C. difficile strains among study sites and analysis of congruence.…”

Section: Bacterial Isolatesmentioning

confidence: 99%

Comparison of Strain Typing Results for Clostridium difficile Isolates from North America

Tenover¹,

Åkerlund

Gerding

et al. 2011

J Clin Microbiol

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Accurate strain typing is critical for understanding the changing epidemiology of Clostridium difficile infections. We typed 350 isolates of toxigenic C. difficile from 2008 to 2009 from seven laboratories in the United States and Canada. Typing was performed by PCR-ribotyping, pulsed-field gel electrophoresis (PFGE), and restriction endonuclease analysis (REA) of whole-cell DNA. The Cepheid Xpert C. difficile test for presumptive identification of 027/NAP1/BI isolates was also tested directly on original stool samples. Of 350 isolates, 244 (70%) were known PCR ribotypes, 224 (68%) were 1 of 8 common REA groups, and 187 (54%) were known PFGE types. Eighty-four isolates typed as 027, NAP1, and BI, and 83 of these were identified as presumptive 027/NAP1/BI by Xpert C. difficile. Eight additional isolates were called presumptive 027/NAP1/BI by Xpert C. difficile, of which three were ribotype 027. Five PCR ribotypes contained multiple REA groups, and three North American pulsed-field (NAP) profiles contained both multiple REA groups and PCR ribotypes. There was modest concordance of results among the three methods for C. difficile strains, including the J strain (ribotype 001 and PFGE NAP2), the toxin A-negative 017 strain (PFGE NAP9 and REA type CF), the 078 animal strain (PFGE NAP7 and REA type BK), and type 106 (PFGE NAP11 and REA type DH). PCR-ribotyping, REA, and PFGE provide different but overlapping patterns of strain clustering. Unlike the other methods, the Xpert C. difficile 027/NAP1/BI assay gave results directly from stool specimens, required only 45 min to complete, but was limited to detection of a single strain type.

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“…In addition, fluoroquinolone exposure has been associated with colonization and infection with other healthcare-associated pathogens, including methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant enterococci (VRE), and Clostridium difficile [3-5]. Reducing the use of fluoroquinolones may be an effective strategy to limit the dissemination of these pathogens [6,7]. For example, a restriction program that resulted in a 66% reduction in use of fluoroquinolones was associated with control of an outbreak of C. difficile infection (CDI) associated with fluoroquinolone-resistant North American pulsed-field gel electrophoresis type 1 (NAP1) strains [7].…”

Section: Introductionmentioning

confidence: 99%

“…Reducing the use of fluoroquinolones may be an effective strategy to limit the dissemination of these pathogens [6,7]. For example, a restriction program that resulted in a 66% reduction in use of fluoroquinolones was associated with control of an outbreak of C. difficile infection (CDI) associated with fluoroquinolone-resistant North American pulsed-field gel electrophoresis type 1 (NAP1) strains [7]. …”

Section: Introductionmentioning

confidence: 99%

Unnecessary use of fluoroquinolone antibiotics in hospitalized patients

et al. 2011

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BackgroundFluoroquinolones are among the most commonly prescribed antimicrobials and are an important risk factor for colonization and infection with fluoroquinolone-resistant gram-negative bacilli and for Clostridium difficile infection (CDI). In this study, our aim was to determine current patterns of inappropriate fluoroquinolone prescribing among hospitalized patients, and to test the hypothesis that longer than necessary treatment durations account for a significant proportion of unnecessary fluoroquinolone use.MethodsWe conducted a 6-week prospective, observational study to determine the frequency of, reasons for, and adverse effects associated with unnecessary fluoroquinolone use in a tertiary-care academic medical center. For randomly-selected adult inpatients receiving fluoroquinolones, therapy was determined to be necessary or unnecessary based on published guidelines or standard principles of infectious diseases. Adverse effects were determined based on chart review 6 weeks after completion of therapy.ResultsOf 1,773 days of fluoroquinolone therapy, 690 (39%) were deemed unnecessary. The most common reasons for unnecessary therapy included administration of antimicrobials for non-infectious or non-bacterial syndromes (292 days-of-therapy) and administration of antimicrobials for longer than necessary durations (234 days-of-therapy). The most common syndrome associated with unnecessary therapy was urinary tract infection or asymptomatic bacteriuria (30% of all unnecessary days-of-therapy). Twenty-seven percent (60/227) of regimens were associated with adverse effects possibly attributable to therapy, including gastrointestinal adverse effects (14% of regimens), colonization by resistant pathogens (8% of regimens), and CDI (4% of regimens).ConclusionsIn our institution, 39% of all days of fluoroquinolone therapy were unnecessary. Interventions that focus on improving adherence with current guidelines for duration of antimicrobial therapy and for management of urinary syndromes could significantly reduce overuse of fluoroquinolones.

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Complete Restriction of Fluoroquinolone Use to Control an Outbreak ofClostridium difficileInfection at a Community Hospital

Cited by 80 publications

References 31 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

Comparison of Strain Typing Results for Clostridium difficile Isolates from North America

Unnecessary use of fluoroquinolone antibiotics in hospitalized patients

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