New long-term data from 2 hospitals in Québec, Cananda, recently assessed the relationship between antibiotic use and healthcare-associated Clostridioides difficile infections. The study aimed to characterize the epidemiology of healthcare-associated Clostridioides difficile infection (HA-CDI) following the 2003 epidemic and to evaluate how antibiotic stewardship affected HA-CDI incidence and the prevalence of the NAP1/027 strain. Reductions in fluoroquinolone usage in these hospitals corresponded with decreased HA-CDI rates and a shift in genotype from NAP1/027 to non-NAP1/027 strains.
- NAP1/027 strain: This genotype, ribotype 027, is associated with increased virulence and resistance to fluoroquinolone antibiotics. It has been implicated in more severe and recurrent cases of CDI.
- Non-NAP1/027 strains are C difficile strains that do not belong to the NAP1/027 genotype. They may vary in virulence factors, and susceptibility to antibiotics compared to the NAP1/027 strain.
Between 2003 and 2020, cases dropped from 26.5 per 10,000 patient days in 2003 to 4.9 cases per 10,000 patient days in 2020, respectively. Throughout the 17-year study period, there was an increase in the use of third-generation cephalosporins, accompanied by decreases using fluoroquinolones and clindamycin. The reduction in fluoroquinolone use was correlated with a significant decrease in HA-CDI incidence and a decrease in the NAP1/027 strain by approximately 80% in both hospitals.
“This decline occurred while total antibiotic consumption was increasing, but the use of certain high-risk antibiotics—fluoroquinolones, second-generation cephalosporins, and clindamycin—was decreasing,” explains investigators. "In the later years of our study, we observed a significant decrease over time in the C difficile NAP1/027 strain which is inherently resistant to fluoroquinolones. There was a parallel significant decrease in fluoroquinolone utilization at one of the two hospitals.”1
3 Key Takeaways
- Findings underscore the importance of antibiotic stewardship in controlling HA-CDI rates and managing resistant strains, emphasizing the need for strategic antibiotic use in hospital settings.
- Decreased use of fluoroquinolones coincided with a significant decline in HA-CDI cases from 26.5 to 4.9 per 10,000 patient-days between 2003 and 2020.
- The decrease in fluoroquinolone usage also led to an approximate 80% reduction in the prevalence of the hypervirulent NAP1/027 strain in both hospitals.
From 2003 to 2020, the incidence of HA-CDI and antibiotic usage were examined alongside available C difficile isolates. The effect of antibiotic usage on HA-CDI incidence was assessed using a dynamic regression time-series model. Antibiotic utilization and the percentage of NAP1/027 strains were biannually compared for isolates available from 2010 to 2020.
“Our findings demonstrated an association between a decrease in fluoroquinolone utilization and a decrease in total C difficile incidence. We were further able to demonstrate that a significant decrease in the incidence of the NAP1/027 strain was concomitant with a decrease in fluoroquinolone utilization at one of our two hospital sites in the final years of the study,” according to investigators.1
According to a recent announcement by WHO addressing challenges in the antibacterial pipeline, they are developing products targeting C difficile and H pylori. This includes 5 antibiotics and 9 non-traditional antibacterial treatments for C difficile, and 1 antibiotic and 1 non-traditional therapy for H pylori. This proves the development of antibacterial agents remains relevant to ensure effective treatment for patients battling these diseases.2
This study has limitations such as only having data from 2 hospitals, warranting broader data collection across multiple institutions to determine the impact of reduced fluoroquinolone use on HA-CDI and the NAP1/027 strain across countries. Various infection control interventions during the study period may confound assessments of antibiotic impacts on HA-CDI. The study did not separately analyze the effects of individual antibiotic classes. Retrospective data access limited a full evaluation of antibiotic effects on NAP1/027 strain dynamics. Reduced fluoroquinolone use correlated with decreased NAP1/027 isolates in both hospitals studied.
According to investigators, “Another possible contributor to the decline in HA-CDI incidence was the move to a single-room facility for the RVH site in 2015. A previous time-series analysis conducted at our institution did not demonstrate an association of HA-CDI incidence and housing patients in single rooms.”1
The decline in HA-CDI in two Montreal hospitals was linked to reduced use of high-risk antibiotics, notably fluoroquinolones. Decreased fluoroquinolone use correlated with significant reductions in both HA-CDI incidence and the proportion of NAP1/027 C difficile strains at one study site. These findings highlight the critical role of antibiotic stewardship in controlling HA-CDI rates and mitigating hypervirulent strains within hospital settings.
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