Journal of Antimicrobial Chemotherapy, Vol 40, 707-711, Copyright © 1997 by The British Society for Antimicrobial Chemotherapy
C McNulty, M Logan, IP Donald, D Ennis, D Taylor, RN Baldwin, M Bannerjee and KA Cartwright
Toxin-producing Clostridium difficile is the commonest bacterial cause of
nosocomial diarrhoea and is a well recognized cause of hospital outbreaks
in elderly care units. High C. difficile disease rates have been associated
with the use of broad-spectrum antibiotics, especially cephalosporins. An
outbreak of C. difficile infection in the elderly care unit at
Gloucestershire Royal NHS Trust continued despite increased ward cleaning
and strict implementation of infection control measures. A restrictive
antibiotic policy that would maintain colonization resistance in the
gastrointestinal tract was introduced throughout this unit. Patients
admitted with suspected infection were prescribed intravenous (i.v.)
benzylpenicillin 1.2-1.8 g every 6 h to cover streptococcal infections and
i.v. trimethoprim 200 mg twice daily to cover urinary tract pathogens and
Haemophilus influenzae. If the patient had septic shock a single iv dose of
gentamicin was given (120- 180 mg) to cover more resistant gram-negative
bacilli. The following were monitored before and after the policy change.
The number of cases of C. difficile toxin-positive diarrhoea; cefuroxime
and total antibiotic use on the elderly care wards; patient mortality
rates; and length of hospital stay: two hundred and fifty-two and 234
patients respectively with a discharge diagnosis of infection were admitted
before and after the antibiotic policy change. Mortality rates and length
of hospital stay were unchanged. Cefuroxime prescribing and total
antibiotic prescribing costs fell by 5150 pounds sterling and 8622 pounds
sterling respectively in the 7 month period after the change. Thirty-seven
cases of C. difficile diarrhoea occurred in the period before and 16 in the
period after the policy change. The incidence of C. difficile diarrhoea and
of cefuroxime use has remained low since then. The use of narrow-spectrum
antibiotics for hospital treatment of community-acquired infections in the
elderly should be encouraged. Outbreaks of C. difficile diarrhoea should be
managed with the combined approach of infection control and strict
antibiotic policies.
ORIGINAL ARTICLES
Successful control of Clostridium difficile infection in an elderly care unit through use of a restrictive antibiotic policy
Public Health Laboratory, Gloucestershire Royal Hospital, UK.
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