Hospital Ward Antibiotic Prescribing and the Risks of Clostridium difficile Infection

Hospital Ward Antibiotic Prescribing and the Risks of Clostridium difficile Infection. Brown, K., Valenta, K., Fisman, D., Simor, A., & Daneman, N. JAMA internal medicine, 175(4):626–633, April, 2015.
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IMPORTANCE: Only a portion of hospital-acquired Clostridium difficile infections can be traced back to source patients identified as having symptomatic disease. Antibiotic exposure is the main risk factor for C difficile infection for individual patients and is also associated with increased asymptomatic shedding. Contact with patients taking antibiotics within the same hospital ward may be a transmission risk factor for C difficile infection, but this hypothesis has never been tested. OBJECTIVES: To obtain a complete portrait of inpatient risk that incorporates innate patient risk factors and transmission risk factors measured at the hospital ward level and to investigate ward-level rates of antibiotic use and C difficile infection risk. DESIGN, SETTING, AND PATIENTS: A 46-month (June 1, 2010, through March 31, 2014) retrospective cohort study of inpatients 18 years or older in a large, acute care teaching hospital composed of 16 wards, including 5 intensive care units and 11 non-intensive care unit wards. EXPOSURES: Patient-level risk factors (eg, age, comorbidities, hospitalization history, antibiotic exposure) and ward-level risk factors (eg, antibiotic therapy per 100 patient-days, hand hygiene adherence, mean patient age) were identified from hospital databases. MAIN OUTCOMES AND MEASURES: Incidence of hospital-acquired C difficile infection as identified prospectively by hospital infection prevention and control staff. RESULTS: A total of 255 of 34 298 patients developed C difficile (incidence rate, 5.95 per 10 000 patient-days; 95% CI, 5.26-6.73). Ward-level antibiotic exposure varied from 21.7 to 56.4 days of therapy per 100 patient-days. Each 10% increase in ward-level antibiotic exposure was associated with a 2.1 per 10 000 (P \textless .001) increase in C difficile incidence. The association between C difficile incidence and ward antibiotic exposure was the same among patients with and without recent antibiotic exposure, and C difficile risk persisted after multilevel, multivariate adjustment for differences in patient-risk factors among wards (relative risk, 1.34 per 10% increase in days of therapy; 95% CI, 1.16-1.57). CONCLUSIONS AND RELEVANCE: Among hospital inpatients, ward-level antibiotic prescribing is associated with a statistically significant and clinically relevant increase in C difficile risk that persists after adjustment for differences in patient-level antibiotic use and other patient- and ward-level risk factors. These data strongly support the use of antibiotic stewardship as a means of preventing C difficile infection.

@article{brown_hospital_2015,
	title = {Hospital {Ward} {Antibiotic} {Prescribing} and the {Risks} of \textit{{Clostridium} difficile} {Infection}},
	volume = {175},
	issn = {2168-6114},
	doi = {10.1001/jamainternmed.2014.8273},
	abstract = {IMPORTANCE: Only a portion of hospital-acquired Clostridium difficile infections can be traced back to source patients identified as having symptomatic disease. Antibiotic exposure is the main risk factor for C difficile infection for individual patients and is also associated with increased asymptomatic shedding. Contact with patients taking antibiotics within the same hospital ward may be a transmission risk factor for C difficile infection, but this hypothesis has never been tested.
OBJECTIVES: To obtain a complete portrait of inpatient risk that incorporates innate patient risk factors and transmission risk factors measured at the hospital ward level and to investigate ward-level rates of antibiotic use and C difficile infection risk.
DESIGN, SETTING, AND PATIENTS: A 46-month (June 1, 2010, through March 31, 2014) retrospective cohort study of inpatients 18 years or older in a large, acute care teaching hospital composed of 16 wards, including 5 intensive care units and 11 non-intensive care unit wards.
EXPOSURES: Patient-level risk factors (eg, age, comorbidities, hospitalization history, antibiotic exposure) and ward-level risk factors (eg, antibiotic therapy per 100 patient-days, hand hygiene adherence, mean patient age) were identified from hospital databases.
MAIN OUTCOMES AND MEASURES: Incidence of hospital-acquired C difficile infection as identified prospectively by hospital infection prevention and control staff.
RESULTS: A total of 255 of 34 298 patients developed C difficile (incidence rate, 5.95 per 10 000 patient-days; 95\% CI, 5.26-6.73). Ward-level antibiotic exposure varied from 21.7 to 56.4 days of therapy per 100 patient-days. Each 10\% increase in ward-level antibiotic exposure was associated with a 2.1 per 10 000 (P {\textless} .001) increase in C difficile incidence. The association between C difficile incidence and ward antibiotic exposure was the same among patients with and without recent antibiotic exposure, and C difficile risk persisted after multilevel, multivariate adjustment for differences in patient-risk factors among wards (relative risk, 1.34 per 10\% increase in days of therapy; 95\% CI, 1.16-1.57).
CONCLUSIONS AND RELEVANCE: Among hospital inpatients, ward-level antibiotic prescribing is associated with a statistically significant and clinically relevant increase in C difficile risk that persists after adjustment for differences in patient-level antibiotic use and other patient- and ward-level risk factors. These data strongly support the use of antibiotic stewardship as a means of preventing C difficile infection.},
	language = {eng},
	number = {4},
	journal = {JAMA internal medicine},
	author = {Brown, Kevin and Valenta, Kim and Fisman, David and Simor, Andrew and Daneman, Nick},
	month = apr,
	year = {2015},
	pmid = {25705994},
	pages = {626--633},
}

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OBJECTIVES: To obtain a complete portrait of inpatient risk that incorporates innate patient risk factors and transmission risk factors measured at the hospital ward level and to investigate ward-level rates of antibiotic use and C difficile infection risk. DESIGN, SETTING, AND PATIENTS: A 46-month (June 1, 2010, through March 31, 2014) retrospective cohort study of inpatients 18 years or older in a large, acute care teaching hospital composed of 16 wards, including 5 intensive care units and 11 non-intensive care unit wards. EXPOSURES: Patient-level risk factors (eg, age, comorbidities, hospitalization history, antibiotic exposure) and ward-level risk factors (eg, antibiotic therapy per 100 patient-days, hand hygiene adherence, mean patient age) were identified from hospital databases. MAIN OUTCOMES AND MEASURES: Incidence of hospital-acquired C difficile infection as identified prospectively by hospital infection prevention and control staff. RESULTS: A total of 255 of 34 298 patients developed C difficile (incidence rate, 5.95 per 10 000 patient-days; 95% CI, 5.26-6.73). Ward-level antibiotic exposure varied from 21.7 to 56.4 days of therapy per 100 patient-days. Each 10% increase in ward-level antibiotic exposure was associated with a 2.1 per 10 000 (P \\textless .001) increase in C difficile incidence. The association between C difficile incidence and ward antibiotic exposure was the same among patients with and without recent antibiotic exposure, and C difficile risk persisted after multilevel, multivariate adjustment for differences in patient-risk factors among wards (relative risk, 1.34 per 10% increase in days of therapy; 95% CI, 1.16-1.57). CONCLUSIONS AND RELEVANCE: Among hospital inpatients, ward-level antibiotic prescribing is associated with a statistically significant and clinically relevant increase in C difficile risk that persists after adjustment for differences in patient-level antibiotic use and other patient- and ward-level risk factors. 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Antibiotic exposure is the main risk factor for C difficile infection for individual patients and is also associated with increased asymptomatic shedding. Contact with patients taking antibiotics within the same hospital ward may be a transmission risk factor for C difficile infection, but this hypothesis has never been tested.\nOBJECTIVES: To obtain a complete portrait of inpatient risk that incorporates innate patient risk factors and transmission risk factors measured at the hospital ward level and to investigate ward-level rates of antibiotic use and C difficile infection risk.\nDESIGN, SETTING, AND PATIENTS: A 46-month (June 1, 2010, through March 31, 2014) retrospective cohort study of inpatients 18 years or older in a large, acute care teaching hospital composed of 16 wards, including 5 intensive care units and 11 non-intensive care unit wards.\nEXPOSURES: Patient-level risk factors (eg, age, comorbidities, hospitalization history, antibiotic exposure) and ward-level risk factors (eg, antibiotic therapy per 100 patient-days, hand hygiene adherence, mean patient age) were identified from hospital databases.\nMAIN OUTCOMES AND MEASURES: Incidence of hospital-acquired C difficile infection as identified prospectively by hospital infection prevention and control staff.\nRESULTS: A total of 255 of 34 298 patients developed C difficile (incidence rate, 5.95 per 10 000 patient-days; 95\\% CI, 5.26-6.73). Ward-level antibiotic exposure varied from 21.7 to 56.4 days of therapy per 100 patient-days. Each 10\\% increase in ward-level antibiotic exposure was associated with a 2.1 per 10 000 (P {\\textless} .001) increase in C difficile incidence. The association between C difficile incidence and ward antibiotic exposure was the same among patients with and without recent antibiotic exposure, and C difficile risk persisted after multilevel, multivariate adjustment for differences in patient-risk factors among wards (relative risk, 1.34 per 10\\% increase in days of therapy; 95\\% CI, 1.16-1.57).\nCONCLUSIONS AND RELEVANCE: Among hospital inpatients, ward-level antibiotic prescribing is associated with a statistically significant and clinically relevant increase in C difficile risk that persists after adjustment for differences in patient-level antibiotic use and other patient- and ward-level risk factors. 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