Incidence of Clostridioides difficile infection (CDI) related to antibiotic prescribing by GP surgeries in Wales.

Florence Tydeman,Rosy Reynolds,Noel Craine,Victoria Mcclure,Harriet Hughes,Matt Hickman,Helen Adams,Chris Robertson,Kimberley Kavanagh

doi:10.1093/jac/dkab204

Abstract

BackgroundClostridioides difficile infection (CDI) is a healthcare-acquired infection (HAI) causing significant morbidity and mortality. Welsh CDI rates are high in comparison with those in England and Scotland.ObjectivesThis retrospective ecological study used aggregated disease surveillance data to understand the impact of total and high-risk Welsh GP antibiotic prescribing on total and stratified inpatient/non-inpatient CDI incidence.MethodsAll cases of confirmed CDI, during the financial years 2014–15 to 2017–18, were linked to aggregated rates of antibiotic prescribing in their GP surgery and classified as ‘inpatient’, ‘non-inpatient’ or ‘unknown’ by Public Health Wales. Multivariable negative-binomial regression models, comparing CDI incidence with antibiotic prescribing rates, were adjusted for potential confounders: location; age; social deprivation; comorbidities (estimated from prevalence of key health indicators) and proton pump inhibitor (PPI) prescription rates.ResultsThere were 4613 confirmed CDI cases, with an incidence (95% CI) of 1.44 (1.40–1.48) per 1000 registered patients. Unadjusted analysis showed that an increased risk of total CDI incidence was associated with higher total antibiotic prescribing [relative risk (RR) (95% CI) = 1.338 (1.170–1.529) per 1000 items per 1000 specific therapeutic group age-sex related GP prescribing units (STAR-PU)] and that high-risk antibiotic classes were positively associated with total CDI incidence. Location, age ≥65 years and diabetes were associated with increased risk of CDI. After adjusting for confounders, prescribing of clindamycin showed a positive association with total CDI incidence [RR (95% CI) = 1.079 (1.001–1.162) log items per 1000 registered patients].ConclusionsAn increased risk of CDI is demonstrated at a primary care practice population level, reflecting their antibiotic prescribing rates, particularly clindamycin, and population demographics.

Highlights

Clostridioides difficile is a bacterium that colonizes the bowel in approximately 5% of adults.[1]
The majority of reported CDI cases are related to a hospital or care-home stay; recent studies indicate that the incidence of community-associated C. difficile infection (CA-CDI) is increasing and may account for up to 30% of all CDI cases.[2,3]
All glutamate dehydrogenase (GDH)-positive/toxin-positive CDI cases reported to the national surveillance system for C. difficile infection were provided by Public Health Wales including, when available, the GP surgery at which the case was registered

Summary

Introduction

Clostridioides difficile is a bacterium that colonizes the bowel in approximately 5% of adults.[1]. Surveillance data in Wales indicate that CDI rates are high in comparison with England and Scotland: 36.7 CDI per 100 000 population in Wales compared with 23.9 CDI per 100 000 in England and 30.1 CDI per 100 000 in Scotland (2017).[4,5,6] CDI in hospitalized patients results in poorer patient outcomes, increased length of hospital stay and treatment costs.[7,8] CDI has a significant effect on patient morbidity and mortality, associated with 30 day all-cause mortality rates of 9%–38% and attributable mortality rates of 5.7%–6.9%.9. Welsh CDI rates are high in comparison with those in England and Scotland

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