A Multi-Year Analysis on Antimicrobial Use on Clostridioides difficile Infection

Infectious Bacteria

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In collaboration with the Centers for Disease Prevention and Control (CDC) through the Emerging Infections Program (EIP), Davidson County, Tennessee, is investigating the impact of previous antimicrobial use on the incidence of Clostridioides difficile infection (CDI) in various age groups.¹

From 2012 to 2020, 7346 confirmed CDI cases were reported in Davidson County, with 5467 (74.4%) of these cases occurring in individuals who had received antibiotics within the 12 weeks before their diagnosis. Analysis shows a decreasing trend in antibiotic prescriptions from 2012 to 2020 with annual percentages recorded as 77.0%, 76.7%, 74.3%, 80.7%, 76.3%, 75.1%, 73.7%, 74.8%, and 71.5% across those years, respectively. This decline began in 2015, after a brief increase over 2014 percentages.

The data were presented by Raquel Villegas, PhD, an assistant professor of medicine at the Vanderbilt University School of Medicine, in a poster presentation at the Society for Healthcare Epidemiology of America (SHEA) Spring 2024 Conference. The meeting was held April 16-19, 2024, in Houston, Texas.

Surveillance data included all confirmed CDI cases in residents aged 1 year and older in Davidson County. Antibiotic usage rates varied by age group: 53.4% in ages 1 to 18 years, 68.8% in ages 19 to 44 years, 74.5% in ages 45-64 years, 79.2% in ages 65 to 74 years, and 83.1% in ages 75 years and older. The top 5 antibiotics prescribed were ceftriaxone (11.1%), vancomycin IV (10.9%), ciprofloxacin (10.2%), metronidazole (9.1%), and piperacillin (8.6%).

The study further analyzed prescription patterns within these age groups, identifying the age group 45 to 64 years as more likely to receive prescriptions for vancomycin IV, ciprofloxacin, metronidazole, and piperacillin-tazobactam (P <.0001). No significant differences were found in ceftriaxone prescriptions among the age groups. Data for this analysis was processed using SAS version 9.4, including only fully documented cases.

Antibiotic prescription rates are potentially modifiable, expanding detailed studies and implementing antibiotic stewardship programs could mitigate CDI risks associated with antibiotic use.

These data from the Tennessee site build on the previously established metrics for CDI incidence rates in the United States, such as the CDC's surveillance data. Surveillance data populations include those from the CDC's EIP sites in California (1 county in the San Francisco area), Colorado (5 counties in the Denver area), Connecticut (1 county in the New Haven area), Georgia (8 counties in the Atlanta area), Maryland (9 Eastern Shore and 2 western counties); Minnesota (5 counties), New Mexico (1 county in the Albuquerque area); New York (1 county in the Rochester area), and Oregon (1 rural county), in addition to the aforementioned Davidson County site.

The CDC's 2021 report was conducted at 10 EIP sites, suggesting a crude overall incidence rate of 110.2 cases per 100,000 persons, with a slightly higher incidence of community-associated cases (55.9 cases per 100,000 persons) compared with healthcare-associated cases (54.3 cases per 100,000 persons). The incidence rate of CDI increased with age and was higher in women than in men and higher in White persons than in persons of other races.²

Previous data from Pechal et al in BMC Infectious Diseases in 2016 supported these rates, as their data suggested that among 2.3 million hospital discharges for CDI over the study period, the incidence was highest among elderly adults (11.6 CDI discharges per 1000 total discharges), who also had higher rates of mortality (8.8%) compared with adults (3.1%) and pediatrics (1.4%) (P <.0001).³

The CDC also recently reported that hospitals implementing its Strategies Framework for preventing hospital-onset CDI demonstrated a more rapid reduction in incidence than the hospitals serving as controls in a quality improvement study—though it noted that the difference could not be attributed to the Framework's effectiveness.⁴ The incidence of hospital-onset infection was already declining in participating hospitals before the intervention, and the rate of decline remained consistent during the implementation of the Framework.

Although the degree to which hospitals implemented the Framework was associated with steeper declines in HO-CDI incidence. Certain interventions within the Framework, such as case reviews, stewardship interventions targeting high-risk antibiotics, and specific testing methods, showed potential benefits despite the low anticipated power to detect such benefits.

References
1. Raquel Villegas, PhD, MS. Age-related Antibiotic Prescribing Trends of Clostridioides Difficile Incident Cases within Davidson County TN 2012-2020. Presented at SHEA 2024; April 16-19; Houston, TX. Poster #119.
2. Emerging Infections Program Healthcare-Associated Infections–Community Interface Report: Clostridioides difficile infection, 2019. CDC. Reviewed February 1, 2023. Accessed April 18, 2024. https://www.cdc.gov/hai/eip/Annual-CDI-Report-2021.html
3. Pechal A, Lin K, Allen S, Reveles K. National age group trends in Clostridium difficile infection incidence and health outcomes in United States Community Hospitals. BMC Infect Dis. 2016;16(1):682. doi:10.1186/s12879-016-2027-8
4. Turner NA, Krishan J, Nelson A, et al. CDC's hospital-onset Clostridioides difficile prevention framework in a regional hospital network. JAMA Netw Open. 2024;7(3):e243846, doi:10.1001/jamanetworkopen.2024.3846