Clostridium Difficile Research Articles

TRPV4 modulates inflammatory responses and apoptosis in enteric glial cells triggered by Clostridioides difficile toxins A and B

Clostridioides difficile, a spore-forming anaerobic bacterium, is the primary cause of hospital antibiotic-associated diarrhea. Key virulence factors, toxins A (TcdA) and B (TcdB), significantly contribute to C. difficile infection (CDI). Yet, the specific impact of these toxins, particularly on enteric glial cells (EGCs), still needs to be fully understood. This study examines the role of the transient receptor potential vanilloid 4 (TRPV4), a calcium-permeable channel, in the inflammatory response and apoptosis of EGCs induced by TcdA and TcdB and evaluates TRPV4 expression in the cecum and colon of infected mice. EGCs were treated with TcdA (50ng/mL) or TcdB (1ng/mL) for 18 h, with or without the TRPV4 antagonist RN-1734 (100 µM), to assess TRPV4 gene and protein levels, inflammatory markers, and cell death. C. difficile infected mice were euthanized on day 3 post-infection for TRPV4 expression in the cecum and colon. Findings reveal that EGCs naturally express TRPV4, increasing its expression by TcdA and TcdB exposure. CDI significantly upregulates TRPV4 in the cecum and colon’s submucosal and myenteric plexus regions. TRPV4 mediates TNF-α release in EGCs and is partially involved in the increase in IL-6 gene expression triggered by these toxins. Our results highlight TRPV4’s role in triggering EGC apoptosis via caspase 3 activation and inhibiting the reduction of Bcl-2, an anti-apoptotic protein in EGCs caused by C. difficile toxins. These results highlight TRPV4’s significant role in CDI pathogenesis and its potential as a therapeutic target to counteract the detrimental effects of C. difficile toxins on enteric glia.

Structure-Based Discovery of Epigallocatechin Gallate and Withaferin A as Inhibitors of Clostridium difficile Toxin Pathogenesis

Structure-Based Discovery of Epigallocatechin Gallate and Withaferin A as Inhibitors of Clostridium difficile Toxin Pathogenesis

Pilot study of Clostridioides difficile infection (CDI) in hospitals, Italy, September to December 2022.

BackgroundClostridioides difficile infection (CDI) is a severe infection that needs to be monitored. This infection predominantly occurs in hospitalised patients after antimicrobial treatment, with high mortality in elderly patients.AimWe aimed at estimating the incidence of CDI in Italian hospitals over 4 months in 2022.MethodsWe estimated incidences of hospital-acquired CDI (HA-CDI), community or unknown CDI (CA/UA-CDI), recurrent CDI and overall CDI in 25 Italian hospitals, characterised C. difficile isolates using PCR ribotyping, analysed them for toxin genes and susceptibility to antimicrobials.ResultsClostridioides difficile was detected in 9.7% (655/6,722) of samples from 550 patients, 18 patients died of CDI. The mean overall CDI incidence was 5.0 cases per 10,000 patient days (range: 0.7-11.9). For HA-CDI, mean incidence was 3.7 (range: 0.7-9.2), for CA/UA-CDI 0.8 (range: 0.0-3.2) and for recurrent CDI 0.5 (range: 0.0-3.4). Most patients were female (n = 295; 53.6%), aged ≥ 65 years (n = 422; 76.7%) and previously hospitalised (n = 275; 50.0%). Of the 270 culturable isolates, 267 (98.9%) had toxin A and B genes and 51 (18.9%) the binary toxin genes. Of the 55 PCR ribotypes (RTs) identified, RT 018 (n = 56; 20.7%) and RT 607 (n = 23; 8.5%) were the most common, RT 607 in the northern (p < 0.0001) and RT 018 in the central (p < 0.0001) regions of Italy. Most isolates (n = 158; 58.5%) were antimicrobial-resistant and 119 (44.1%) were multidrug-resistant (MDR).ConclusionHighly virulent and MDR C. difficile types are circulating in Italian hospitals which highlights the need of robust surveillance and stringent prevention and control measures.

Modulating the microbiome in chronic liver diseases- current evidence on the role of fecal microbiota transplantation.

The gut microbiota has a complex relationship with the human host and is key to maintaining health. Disruption of the healthy diverse gut microbial milieu plays an important role in the pathogenesis of several diseases including Clostridioides difficile infection (CDI), inflammatory bowel disease, irritable bowel syndrome, alcohol-related liver disease and metabolic-dysfunction associated steatotic liver disease (MASLD). Fecal microbiota transplantation (FMT) is highly effective in treating CDI, though its utility in other diseases is still being explored. In this narrative review, we explore the role of gut microbiota in liver diseases, focusing on key changes in the microbial composition and function. We summarize current evidence on the role of FMT, identifying gaps in current research and outlining future directions for investigation. We comprehensively searched PubMed through 15 October 2024 to identify relevant studies. While data from available studies shows promise, more research is necessary before we can use FMT for liver diseases. Key areas that require further study are- determining the optimal FMT regimen for each disease, establishing efficacy and safety with larger clinical trials, ensuring safe and equitable access to the FMT product and mechanistic insights into the reasons for success or failure of FMT.

Using nutrition to help recovery from infections.

Antibiotics are a cornerstone of modern medicine, but antibiotic consumption can have depleting effects on the gut microbiota, potentially leading to gastrointestinal symptoms and other diseases, namely Clostridioides difficile infection. Because nutrition is a major driver of gut microbiota diversity and function, here we explore the current evidence on the potential of diets in alleviate the deleterious effects of antibiotics consumed during infections. Beneficial nutrients can enhance the symbiotic effect of the gut microbiota with the host, supporting anti-inflammatory responses and maintaining tight junction integrity. Short-chain fatty acids have been shown to positively affect the immune response, reducing the severity of C. difficile infection, whereas high-fibre diets have been shown to promote faster recovery of the gut microbiota after antibiotic therapy. The role of nutrition during infection is gaining momentum, with key findings exploring the effect of some nutrients in limiting the severity of infections and helping the microbiota recover from antibiotic-induced dysbiosis. Although this field is in its infancy, these findings open the possibility of personalised nutrition as a way of restoring microbiome diversity. But more work is needed to identify the most effective types and combinations of nutrients to achieve this.

Exploring the epidemiology, pathogenesis, and immunotherapeutic advancements in &lt;i&gt;Clostridium difficile&lt;/i&gt; infection

&lt;p&gt;&lt;i&gt;Clostridium difficile&lt;/i&gt; (&lt;i&gt;C. difficile&lt;/i&gt;) is a gram-positive, spore-forming bacillus that thrives in anaerobic conditions. It serves as the primary causative agent for various diseases globally, including nosocomial antibiotic-associated diarrhea and pseudomembranous colitis, potentially leading to fatal outcomes. The production of up to three toxins by this bacterium is considered its primary virulence mechanism in &lt;i&gt;C. difficile&lt;/i&gt; infection (CDI). These toxins initiate inflammation, cause tissue damage, and result in diarrhea. Conventional antibiotic treatments for CDI not only substantially reduce intestinal microbiota but also increase CDI recurrence rates. Immunotherapy has emerged as a promising approach for combating CDI, offering a novel strategy to target this challenging pathogen. Various immunotherapeutic modalities, such as monoclonal antibodies targeting specific &lt;i&gt;C. difficile&lt;/i&gt; toxins, fecal microbiota transplantation (FMT) to restore microbial balance, and vaccines to stimulate protective immune responses, have shown potential in preclinical and clinical studies. This review examines the current landscape of immunotherapy for CDI, highlighting significant advancements, challenges, and future directions in utilizing the immune system to address this substantial healthcare burden.&lt;/p&gt;

Impact of order set implementation on appropriate treatment of community-acquired pneumonia (CAP).

This study aimed to evaluate appropriate antimicrobial prescribing after implementing a pneumonia order set within a community teaching hospital. Retrospective chart review study. 450-bed community teaching hospital. Patients who are 18 years of age or older admitted for treatment of community-acquired pneumonia (CAP) between October 1, 2021, and August 1, 2023. This retrospective cohort study aimed to evaluate a composite endpoint of appropriate empiric antimicrobial selection, dosing, and duration in accordance with the national guidelines after the implementation of a CAP order set. Secondary outcomes included comparing hospital length of stay (LOS), readmission rates, mortality rates, and Clostridium difficile infection rates. A total of 236 patients were included (118 patients per group). Significantly more patients in the post-implementation group received guideline-concordant therapy for CAP (5.9% vs 35.6%, P < .001). Results were heavily influenced by improvements in appropriate durations of therapy (pre: 6.8% vs post: 39.9%, P < .001). There were no significant differences observed for LOS, 30-day readmission rates, C. difficile infections within 30 days, or mortality rates between groups. The order set was utilized in 66.1% of patients included in the post-implementation group. Implementing an order set significantly improved inpatient antibiotic prescribing for CAP with no difference in clinical or safety outcomes. Antibiotic order sets will be a useful tool for antimicrobial stewardship program expansion into other common community-acquired infections.

Sex differences in gut microbiota, hypertension, and cardiovascular risk.

The intricate ecosystem of the gut microbiome exhibits sex-specific differences, influencing the susceptibility to cardiovascular diseases (CVD). Imbalance within the gut microbiome compromises the gut barrier, activates inflammatory pathways, and alters the production of metabolites, all of which initiate chronic diseases including CVD. In particular, the interplay between lifestyle choices, hormonal changes, and metabolic byproducts uniquely affects sex-specific gut microbiomes, potentially shaping the risk profiles for hypertension and CVD differently in men and women. Understanding the gut microbiome's role in CVD risk offers informative reasoning behind the importance of developing tailored preventative strategies based on sex-specific differences in CVD risk. Furthermore, insight into the differential impact of social determinants and biological factors on CVD susceptibility emphasizes the necessity for more nuanced approaches. This review also outlines specific dietary interventions that may enhance gut microbiome health, offering a glimpse into potential therapeutic avenues for reducing CVD risk that require greater awareness. Imbalance in natural gut microbiomes may explain etiologies of chronic diseases; we advocate for future application to alter the gut microbiome as possible treatment of the aforementioned diseases. This review mentions the idea of altering the gut microbiome through interventions such as fecal microbiota transplantation (FMT), a major application of microbiome-based therapy that is first-line for Clostridium difficile infections and patient-specific probiotics highlights more innovative approaches to hypertension and CVD prevention. Through increased analysis of gut microbiota compositions along with patient-centric probiotics and microbiome transfers, this review advocates for future preventative strategies for hypertension.

Investigating the Effects of Nosocomial Clostridioides difficile Infection Among Acute Leukemia Patients: Insights From the 2020 National Inpatient Sample.

Rising nosocomial Clostridioides difficile infections pose high risks, especially for immunocompromised leukemia patients, necessitating targeted research to enhance patient care and outcomes.The objective of this study was to investigate the impact of nosocomial Clostridioides difficile infections (CDI) on patients hospitalized with acute lymphoblastic leukemia (ALL) and acute myeloid leukemia (AML). Our study was a retrospective analysis of adult patients hospitalized with a primary diagnosis of ALL or AML, using the Nationwide Inpatient Sample (NIS) database for 2020. Primary outcomes included the incidence of nosocomial CDI and all-cause inpatient mortality. Secondary outcomes included hospital length of stay, resource utilization, and morbidity. Statistical analyses were conducted with STATA (address). Fisher's exact test was utilized to compare proportions, while the Student's t test was employed for continuous variables. Multivariate logistic and linear regression analyses were used to adjust for confounding variables. We found in 21 135 ALL and 58 560 AML adult patients that the CDI incidences were 2.77% and 3.0%, respectively. ALL and AML patients with CDI had adjusted mortality odds ratios of 3.02 (P = .003) and 1.51 (P = .02). Hospital length of stay was extended by mean differences of 10.16 days (ALL) and 8.33 days (AML) for those with CDI compared to those without it. In addition, patients with CDI displayed a significantly higher incidence of acute kidney injury, sepsis, vasopressor use, and intensive care unit admissions. This study highlights the significant impact of CDI infections on health outcomes for leukemia patients, emphasizing the need for robust infection control measures, early detection, and aggressive management of CDI to improve patient outcomes and minimize healthcare costs.

The economic burden of post-endoscopic retrograde cholangiopancreatography (ERCP) procedure infections in Italy

Introduction: The infections of multidrug-resistant organisms (MDROs) associated with duodenoscopes during endoscopic retrograde cholangiopancreatography (ERCP) procedure have become a significant cause for concern, especially in fragile patients. While the clinical impacts of these infections are well-documented, their economic implications remain underexplored. This study assesses the incidence and economic burden of post-ERCP infections in Italy using an administrative database. Methods: We conducted a retrospective observational study using administrative databases from A.O.U. Città della Salute e della Scienza di Torino. The study included all patients who underwent their first inpatient ERCP between 2018 and 2021. Infections were identified using ICD-9-CM codes for Pseudomonas aeruginosa, Clostridium difficile, Escherichia coli, Klebsiella spp., and Staphylococcus aureus. A 1-year follow-up was defined in order to estimate healthcare resource utilization and related costs, including readmissions, drug prescriptions, and outpatient specialist and laboratory services. Results: The study included 686 inpatient ERCP cases, an overall infection rate of 4.2% was observed. Higher infection rates were observed in women (4.6%), patients over 70 years old (4.6%), emergency admissions (5.1%), and transplant patients (19.1%). The average hospital stay doubled for infected patients (24.3 vs. 11.3 days; p=0.001). Post-ERCP infections led to a 28% increase in average costs (€12,256 vs. €9,561; p=0.048). With an annual volume of 25,000 ERCP procedures, post-ERCP infections in Italy contribute approximately €2.9 million in additional direct costs per year. Conclusion: Post-ERCP infections impose substantial financial burdens on the healthcare system, underscoring the critical importance of implementing cost-effective prevention strategies to mitigate this public health threat in Italy.

The impact of the COVID-19 pandemic on the course of Clostridioides difficile infection in patients with inflammatory bowel disease

The impact of the COVID-19 pandemic on the course of Clostridioides difficile infection in patients with inflammatory bowel disease

Diagnosis of Clostridium Difficile: A Wrong Algorithm and an Improvement in Immunoassays

Diagnosis of Clostridium Difficile: A Wrong Algorithm and an Improvement in Immunoassays

Acetaminophen administration reduces acute kidney injury risk in critically ill patients with Clostridium difficile infection: A cohort study.

Acetaminophen serves as a standard antipyretic and analgesic agent in the intensive care unit (ICU). However, the association between its administration and acute kidney injury (AKI) among critically ill patients remains controversial, particularly lacking research in patients with Clostridioides difficile infection (CDI). Our aim was to explore the potential relationship between early acetaminophen administration and AKI in critically ill patients with concurrent CDI. Using data from the Medical Information Mart for Intensive Care (MIMIC) IV version 2.2 database, we performed a retrospective cohort study. AKI within 7 days of ICU admission was the main outcome that was measured. We utilized multivariable logistic regression models adjusted for potential confounders based on statistical significance and clinical relevance, to investigate the association between acetaminophen exposure and the risk of AKI in patients with CDI. Additionally, subgroup analyses and sensitivity analysis were conducted to assess the robustness of our primary findings. The average age of 984 participants was 66.8 ± 16.5 years, and 52.7% (519) were male. The overall proportion of patients who developed AKI was 75.4% (742/984). In patients without and with acetaminophen administration, AKI rates were 79.8% (380/476) and 71.3% (362/508), respectively. Compared to the non-acetaminophen administration group, the risk of AKI was lower in the acetaminophen administration group (absolute risk difference: -8.5%, 95%CI: -13.83%∼-3.17%, P < 0.01).After adjusting for potential confounders, acetaminophen administration was associated with a 32% reduction in the risk of AKI (OR = 0.68, 95%CI:0.48∼0.96, P = 0.027). Our study suggests that early acetaminophen administration may offer renal protection by reducing the risk of AKI in critically ill patients with CDI. Prospective, multicenter randomized controlled studies are needed to verify this finding.

Evaluating Harms Associated with Prolonged Antibiotic Duration of Therapy in Community Dwelling Older Adults: A Cohort Study using Instrumental Variable Analysis.

Shorter courses of antibiotic therapy are increasingly recommended to reduce antibiotic exposure. However quantifying the real-world impact of duration of therapy is hindered by bias common in observational studies. We aimed to evaluate the harms and benefits of longer versus shorter duration of therapy in older adults. This was a population-based cohort study using administrative health data from Ontario, Canada. We included outpatients aged 66 to 110 years who received a prescription for amoxicillin, cephalexin, and/or ciprofloxacin. Prescriptions were categorized as short (3-7 days) or long (8-14 days) duration. The primary outcome was a composite of antibiotic-related harms, including adverse reactions, Clostridioides difficile infection, and antibiotic resistance. The secondary outcome was a composite of safety measures including repeat antibiotic prescriptions, hospital visits and mortality. To reduce risk of bias, we used an instrumental variable analysis where the instrument was prescriber proportion of antibiotics that were long duration. Among 117,682 eligible patients, there was no difference in the primary harms outcome for patients receiving longer versus shorter courses of antibiotics (amoxicillin ORadj 0.99 (95%CI 0.84 to 1.15), cephalexin ORadj 1.11 (95%CI: 0.90 to 1.38), ciprofloxacin ORadj 0.94 (95%CI 0.74 to 1.20). Secondary safety outcomes were similar, with longer compared to shorter courses of antibiotic therapy (amoxicillin OR 1.01 (95%CI: 0.94 to 1.08), cephalexin OR 1.06 (95%CI 0.97 to 1.17), ciprofloxacin OR 0.99 (95%CI: 0.85 to 1.15)). In this instrumental variable analysis of community-dwelling older adults, longer antibiotic courses were not associated with an increased benefit or harm compared to shorter courses.

Incomplete documentation of β-lactam allergy in long-term care facility residents increases risk of high-risk antibiotic use for Clostridioides difficile infection.

In an effort to expedite the publication of articles, AJHP is posting manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time.

Can Gut Microbiota Analysis Reveal Clostridioides difficile Infection? Evidence from an Italian Cohort at Disease Onset

A diverse and well-functioning gut microbiota normally serves as a protective shield against the invasion of harmful bacteria or the proliferation of opportunistic pathogens. Clostridioides difficile infection (CDI) is predominantly associated with the overuse of antibiotics, resulting in a significant alteration in the gut’s microbial balance. Unfortunately, the lack of global standardization does not allow for the identification of a set of biomarkers associated with the onset and progression of this disease. In this study, we examined the composition of the gut microbiota in patients at the time of the initial detection of CDI compared to a control group of CDI-negative individuals, with a focus on identifying potential CDI biomarkers for diagnosis. While no significant differences in the alpha and beta diversity between CDI-negative and CDI-positive individuals were found, we found that certain genera (such as Clostridium XIVa and Clostridium XVIII) showed different abundance patterns in the two groups, indicating potential differences in gut microbiota balance. In conclusion, am enrichment in Clostridium XI and a decrease in Faecalibacterium emerged in the CDI-positive patients and following antibiotic treatment, indicating that changes in the Clostridium/Faecalibacterium ratio may be a promising biomarker that warrants further investigation for CDI diagnosis.

Clostridioides difficile Infection and Testing Rates in South Africa: A multicentre study, 2017-2020.

To describe Clostridioides difficile infection (CDI) rates and testing practices, at three tertiary/quaternary hospitals in South Africa (SA) for the period 2017 to 2020. A retrospective laboratory record review of all C. difficile testing at the Charlotte Maxeke Johannesburg Academic Hospital (CMJAH), Tygerberg Hospital (TBH) and Inkosi Albert Luthuli Central Academic Hospital (IALCH) was performed. Clinical records of patients with rCDI were reviewed to determine recurrent CDI (rCDI) rates. The median primary CDI rates per 10,000 patient-days (PD) were 5.3 at CMJAH, 1.8 at TBH, and 0.3 at IALCH. In 2020, all hospitals reported an increase in primary CDI rates compared to 2019. The median testing rates per 10,000 PD were 39 at CMJAH, 14 at TBH, and 4 at IALCH. The median age of patients with primary CDI was 33 years (IQR: 22-45 years). The rCDI rates ranged from 2 to 5 per 100 incident episodes. Significant variations in CDI and testing rates were observed across the three hospitals. An increase in CDI rates was noted at all centres during the 2020 SARS-CoV-2 outbreak. Advanced age was not prevalent in the cohort, and rCDI rates were relatively low. These findings highlight the need for systematic surveillance of healthcare-onset CDI across SA hospitals.

Prevalence and sequelae of asymptomatic Clostridioides difficile colonization in children with inflammatory bowel disease.

Colonization by Clostridioides difficile is common in children with inflammatory bowel disease (IBD) and complicates both the management of IBD and the diagnosis of C. difficile infection (CDI). There is a paucity of data on rates, risk factors, and outcomes associated with asymptomatic C. difficile colonization in children with IBD. We enrolled and prospectively followed 87 children with IBD without acute gastrointestinal symptoms. Twelve patients (13.8%) tested positive for C. difficile and were considered to have asymptomatic colonization. Elevated white blood cell count was associated with C. difficile colonization based on univariate regression. Three of the 12 (25%) C. difficile colonized patients were diagnosed with CDI in the 90 days following screening for C. difficile, versus 0 of the 75 who tested negative for C. difficile (p = 0.002). This data set the stage for further longitudinal tracking of children with IBD for C. difficile colonization and associated outcomes.

Clinical Practices of Antimicrobial Drugs in Various Hospital-Acquired Infections- A Review Article

Hospital-acquired infections (HAIs) are a significant concern in healthcare settings, resulting in increased morbidity, mortality, and healthcare costs. Effective management of HAIs relies on appropriate antimicrobial therapy. This research paper aims to review the current clinical practices of antimicrobial drugs in various types of HAIs, including pneumonia, urinary tract infections (UTIs), surgical site infections (SSIs), and bloodstream infections (BSIs). By examining the latest evidence-based guidelines, this paper provides insights into the optimal selection, dosing, and duration of antimicrobial therapy for different HAIs. It also explores the challenges associated with antimicrobial stewardship and the role of multidisciplinary approaches in optimizing patient outcomes while minimizing antimicrobial resistance. Effective management of bacterial infections relies on selecting appropriate antimicrobial drugs, considering factors like infection type, severity, local resistance, and patient characteristics. Gram-positive bacteria are treated with drugs like penicillin, cephalosporins, vancomycin, linezolid, and daptomycin for pathogens like Streptococcus pneumoniae and MRSA. Gram-negative bacteria are targeted using beta-lactams, fluoroquinolones, aminoglycosides, carbapenems, and polymyxins for organisms like Escherichia coli, Klebsiella pneumoniae, and Pseudomonas aeruginosa. Atypical bacteria like Chlamydia pneumoniae and Mycoplasma pneumoniae are susceptible to macrolides and tetracyclines. Anaerobic bacteria, including Bacteroides fragilis and Clostridium difficile, are treated with metronidazole, while aerobic bacteria like Escherichia coli and Staphylococcus aureus may require fluoroquinolones and beta-lactams. Antimicrobial stewardship programs are essential for responsible antibiotic use, minimizing resistance development, and improving patient outcomes. KEYWORDS: hospital-acquired infections, antimicrobial drugs, clinical practices, pneumonia, urinary tract infections, surgical site infections, bloodstream infections.

Evaluating academic detailing as an antibiotic stewardship intervention in primary healthcare settings in Croatia

BackgroundAcute respiratory tract infections are common in primary healthcare care settings and frequently result in antibiotic prescriptions, despite being primarily viral. There is scarcity of research examining impact of academic detailing (AD) intervention on prescribing practices for these infections in resource-constrained healthcare settings like southeastern Europe. Therefore aim of this study was to evaluate impact of AD intervention as an antimicrobial stewardship measure on antibiotic prescribing for acute respiratory tract infections in primary setting in Croatia which is located in southeastern Europe. Secondary goal included examining incidence of Clostridioides difficile infections (CDI) which are often associated with antibiotic consumption.MethodsAD intervention was implemented from 1st to 30th April 2020 and led by hospital healthcare professionals (infectious disease physician, clinical microbiology physician and clinical pharmacist). They focused on enhancing prescribing behaviors of primary care physicians (PCPs) by presenting local data, supplemented by examples from everyday practice, research and guidelines highlighting negative consequences of imprudent antibiotic use. This feasibility quasi-experimental study had two control groups in two counties. Impact of AD intervention was assessed by analyzing antibiotic prescription patterns using log-linear model, adjusting for seasonality. Study focused on prescribed daily defined doses (DDD) per day among PCPs pre-intervention (from 01st January 2018 to 31st March 2020) and post-intervention (from 1st May 2020 to 31st December 2022).ResultsData was collected from sixteen out of fifty-seven eligible PCPs with mean 29 years (SD 11.38) in practice. Statistically significant difference results (p < 0.05) favored AD intervention, leading to 30% decline in antibiotic prescribing in adjusted DDD per day for acute pharyngitis (21.14 post-intervention/30.27 pre-intervention), 33% decline for acute tonsilitis (24.91/37.38), 23% decline for acute upper respiratory infection (21.26/27.62) and 36% decline for acute bronchitis (8.13/12.77). Although there was 14% decline for acute sinusitis post-intervention, it did not reach statistical significance (30.96/35.93) (p = 0.617). Incidence of CDI cases decreased in investigated county while in control county stayed the same. Inter-county difference in these changes was not statistically significant (ratio = 0.749, 95% CI, 0.460–1.220; p = 0.246).ConclusionsThis feasibility study showed reductions in antibiotic prescribing for acute respiratory tract infections, emphasizing the efficacy of targeted, educator-led programs. Tailored healthcare strategies are vital, especially in Croatia and southeastern Europe, for promoting sustainable practices and addressing antimicrobial resistance challenges.