Risk factors for Clostridium difficile toxin-positive diarrhea: a population-based prospective case-control study.

Increased incidence and severity of Clostridium difficile infections (CDIs) is of major concern. However, by minimizing known risk factors, the incidence can be decreased. The aim of this investigation was to calculate the incidence and assess risk factors for CDI in our population. A 1-year prospective population-based nationwide study in Iceland of CDIs was carried out. For risk factor evaluation, each case was matched with two age- and sex-matched controls that tested negative for C. difficile toxin. A total of 128 CDIs were identified. The crude incidence was 54 cases annually per 100,000 population >18 years of age. Incidence increased exponentially with older age (319 per 100,000 population >86 years of age). Community-acquired origin was 27 %. Independent risk factors included: dicloxacillin (odds ratio [OR]: 7.55, 95 % confidence interval [CI]: 1.89-30.1), clindamycin (OR: 6.09, 95 % CI: 2.23-16.61), ceftriaxone (OR: 4.28, 95 % CI: 1.59-11.49), living in a retirement home (OR: 3.9, 95 % CI: 1.69-9.16), recent hospital stay (OR: 2.3, 95 % CI: 1.37-3.87). Proton pump inhibitors (PPIs) were used by 60/111 (54 %) versus 91/222 (41 %) (p = 0.026) and ciprofloxacin 19/111 (17 %) versus 19/222 (9 %) (p = 0.027) for cases and controls, respectively. In all, 75 % of primary CDIs treated with metronidazole recovered from one course of treatment. CDI was mostly found among elderly patients. The most commonly identified risk factors were broad-spectrum antibiotics and recent contact with health care institutions. PPI use was significantly more prevalent among CDI patients.

[Analysis of antibiotic utilization review at Landspitalinn, the University Hospital in Iceland.].

OBJECTIVE: To describe the application of and analyze the cost effects of antibiotic utilization review at Landspitalinn, the National University Hospital in Iceland, and review the use of prophylactic antibiotics in a general surgical ward. MATERIAL AND METHODS: The study was undertaken during a two month period in 1996. Patients in wards 11-A and 11-B (general medical floors), ward 12-G (general surgery service) and 11-E (hematology service) were enrolled. A specialist in infectious diseases and a clinical pharmacist reviewed the antibiotic treatment daily. If felt appropriate a recommendation to change treatment was forwarded. The number of patients treated with antibiotics, recommendations, recommendations accepted, and types of suggestions were recorded. Minimal savings per day were calculated by subtracting the cost of the antibiotic treatment after recommended modifications from the cost of the previous treatment. Prophylactic surgical treatment was examined in ward 12-G during an additional month. RESULTS: One hundred and fifty patients were treated with antibiotics during January and February 1996. The percentage of cases where changes in antibiotic treatment was recommended was 74% in 12-G, 65% in 11-E but 33% and 32% in 11-A and 11-B respectively. In ward 11-E, 80% of the recommendations were accepted and appropriate changes made, corresponding figures for the other wards were 93-100%. The most frequently recommended changes were stopping antibiotics (33%), reducing doses (31%) and switching to oral agents (19%). The minimum savings were estimated at ISK 210 000 per month if the effects of recommendations that were accepted were presumed to have lasted three days. Four percent of prescribed prophylactic surgical treatment was according to approved standards. CONCLUSIONS: The results confirm the need to optimize the use of antibiotics at The National University Hospital. The antibiotic utilization review was well received and acceptance of recommendations was high. The application of antibiotic utilization review to the entire hospital could reduce antibiotic cost by as much as 30-36%.