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Open Forum Infect Dis. 2015 Aug 11;2(3):ofv113. doi: 10.1093/ofid/ofv113. eCollection 2015 Sep.

Association Between Outpatient Antibiotic Prescribing Practices and Community-Associated Clostridium difficile Infection.

Author information

1
Centers for Disease Control and Prevention , Atlanta.
2
Centers for Disease Control and Prevention , Atlanta ; Atlanta Research and Education Foundation, Georgia.
3
Colorado Department of Public Health and Environment, Denver.
4
Oregon Health Authority , Portland.
5
University of Rochester Medical Center , New York.
6
Emory University , Atlanta ; Atlanta Veterans Affairs Medical Center , Georgia.
7
Minnesota Department of Health, St. Paul.
8
Connecticut Emerging Infections Program , New Haven.
9
University of New Mexico , Albuquerque.
10
Maryland Emerging Infections Program Baltimore ; Johns Hopkins Bloomberg School of Public Health , Baltimore, Maryland.
11
University of California , San Francisco ; San Francisco General Hospital , California.

Abstract

BACKGROUND:

 Antibiotic use predisposes patients to Clostridium difficile infections (CDI), and approximately 32% of these infections are community-associated (CA) CDI. The population-level impact of antibiotic use on adult CA-CDI rates is not well described.

METHODS:

 We used 2011 active population- and laboratory-based surveillance data from 9 US geographic locations to identify adult CA-CDI cases, defined as C difficile-positive stool specimens (by toxin or molecular assay) collected from outpatients or from patients ≤3 days after hospital admission. All patients were surveillance area residents and aged ≥20 years with no positive test ≤8 weeks prior and no overnight stay in a healthcare facility ≤12 weeks prior. Outpatient oral antibiotic prescriptions dispensed in 2010 were obtained from the IMS Health Xponent database. Regression models examined the association between outpatient antibiotic prescribing and adult CA-CDI rates.

METHODS:

 Healthcare providers prescribed 5.2 million courses of antibiotics among adults in the surveillance population in 2010, for an average of 0.73 per person. Across surveillance sites, antibiotic prescription rates (0.50-0.88 prescriptions per capita) and unadjusted CA-CDI rates (40.7-139.3 cases per 100 000 persons) varied. In regression modeling, reducing antibiotic prescribing rates by 10% among persons ≥20 years old was associated with a 17% (95% confidence interval, 6.0%-26.3%; P = .032) decrease in CA-CDI rates after adjusting for age, gender, race, and type of diagnostic assay. Reductions in prescribing penicillins and amoxicillin/clavulanic acid were associated with the greatest decreases in CA-CDI rates.

CONCLUSIONS AND RELEVANCE:

 Community-associated CDI prevention should include reducing unnecessary outpatient antibiotic use. A modest reduction of 10% in outpatient antibiotic prescribing can have a disproportionate impact on reducing CA-CDI rates.

KEYWORDS:

Clostridium difficile; antibacterial agents; epidemiology; outpatients; public health surveillance

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