Overprescribing of Certain Antibiotics Might Cause C Diff

One of the steps hospitals and other health care providers wanting to contain the spread of Clostridioides difficile (C diff) should be to drastically curtail the prescribing of carbapenems and third- and fourth-generation cephalosporin antibiotics. Patients with C diff are almost twice as likely to have been given those medications, according to a study in the Journal of Antimicrobial Chemotherapy. Investigators with Australian National University conducted a meta-analysis of studies from various sources with the data collected from January 1, 2013 to December 31, 2020. In all, the meta-analysis looks at 21 studies published since 2013, as well as 16 studies identified in earlier reviews.

“Eligible studies were those conducted among adult hospital inpatients, measured exposure to individual antibiotics or antibiotic classes, included a comparison group and measured the occurrence of HCFA-CDI [healthcare facility-associated Clostridioides difficile infection] as an outcome,” the study states.

Investigators note that C diff is the leading cause of health care-acquired infections (HAIs) in modern industrialized nations and is the most common cause of diarrhea in health care facilities. Most of the data were collected from studies conducted in North American and Europe, and the risk that C diff poses may differ from one region to another. It will “depend on the local prevalence of strains that are resistant to the particular antibiotic and a certain degree of heterogeneity is therefore to be expected,” the study states.

What investigators call “modest associations” with C diff were also observed with “quinolones (predominantly fluoroquinolones), lincosamides (namely clindamycin), 2nd generation cephalosporins, and beta-lactamase inhibitor combination penicillin antibiotics.”

Investigators say that one of the limitations of their approach was that antibiotic prescribing and the onset of C diff were not always recorded in an adequate manner, so cause and effect were hard to track. “This could explain the associations found for antibiotics used to treat CDI such as vancomycin and metronidazole (glycopeptide and nitromidazole classes, respectively), although this could not be established in this review, and both are able to incite CDI,” the study states. “Future studies should clearly report the parameters of exposure measurement, including all sources of information on exposure, as it was often unclear particularly in studies with a longer exposure window whether in-hospital prescription only was recorded, or whether prescription in the community setting was included. Information on dose-response relationships is generally lacking and studies investigating the risk of HCF-CDI associated with the timing and duration of antibiotic exposure are needed.”

The study comes at a time when—despite all the attention and health care resources being thrown at COVID-19—medical experts have begun to turn a wary eye toward bacteriological pathogens. The recent launch of an effort by the Centers for Disease Control and Prevention (CDC) to improve antibiotic overprescribing by over 90% for some conditions and some medicines by 2025, underscores the concern about what havoc bacterial superbugs will wreck in the next pandemic—a possible occurrence that most people don’t want to think about, but which health care providers must be on the lookout for. And just as infection preventionists (IPs) manned the frontlines against COVID-19, they will almost certainly be a part of antibiotic stewardship programs to help stave of any possible bacteriological damage.

As Arjun Srinivasan, MD, the CDC’s associate director for health care association infection prevention programs recently told Infection Control Today®: “I think that the key is for the infection preventionists to make sure that they’re connected with their stewardship programs. And I think in almost every instance where I interact with hospitals, that connection is already present, and it’s very strong. But I think these data do help us understand that there are some great opportunities here.”

C diff is one of the superbugs on the CDC’s urgent list. (The CDC divides the threat level of the pathogens—aside from urgent, there’s also “serious,” “concerning,” and “watch” lists.)