ABx_CDI_2

ABx_CDI_

ABx_CDI

The following R (www.r-project.org) code re-creates the analyses and output for the results section of (Brown KA, Khanafer N, Daneman N, Fisman DN. Antibiotics and the risk of community-associated Clostridium difficile infection (CDI): a meta-analysis. Antimicrob. Agents Chemother. 2013). The analyses are divided into sections A-F which correspond to the subheadings in the original article's results section

The Magnitude and Duration of <i>Clostridium difficile</i> Infection Risk Associated with Antibiotic Therapy: A Hospital Cohort Study

<div><p>Antibiotic therapy is the principal risk factor for <i>Clostridium difficile</i> infection (CDI), but little is known about how risks cumulate over the course of therapy and abate after cessation. We prospectively identified CDI cases among adults hospitalized at a tertiary hospital between June 2010 and May 2012. Poisson regression models included covariates for time since admission, age, hospitalization history, disease pressure, and intensive care unit stay. Impacts of antibiotic use through time were modeled using 4 measures: current antibiotic receipt, time since most recent receipt, time since first receipt during a hospitalization, and duration of receipt. Over the 24-month study period, we identified 127 patients with new onset nosocomial CDI (incidence rate per 10,000 patient days [IR] = 5.86). Of the 4 measures, time since most recent receipt was the strongest independent predictor of CDI incidence. Relative to patients with no prior receipt of antibiotics in the last 30 days (IR = 2.95), the incidence rate of CDI was 2.41 times higher (95% confidence interval [CI] 1.41, 4.13) during antibiotic receipt and 2.16 times higher when patients had receipt in the prior 1–5 days (CI 1.17, 4.00). The incidence rates of CDI following 1–3, 4–6 and 7–11 days of antibiotic exposure were 1.60 (CI 0.85, 3.03), 2.27 (CI 1.24, 4.16) and 2.10 (CI 1.12, 3.94) times higher compared to no prior receipt. These findings are consistent with studies showing higher risk associated with longer antibiotic use in hospitalized patients, but suggest that the duration of increased risk is shorter than previously thought.</p></div

Selected Characteristics of Case and Control Patients, Sunnybrook Hospital, Toronto, Canada, June 2010 to May 2012.

<p>Abbreviations: PPI, proton pump inhibitor; ICU, intensive care unit; IQR, interquartile range.</p>a<p>equal to the number of patients diagnosed with CDI in the same ward as a given patient each day.</p>b<p>2 degree of freedom Pearson's Chi-square test.</p><p>Selected Characteristics of Case and Control Patients, Sunnybrook Hospital, Toronto, Canada, June 2010 to May 2012.</p

The Magnitude and Duration of <i>Clostridium difficile</i> Infection Risk After Antibiotic Therapy, Sunnybrook Hospital, Toronto, Canada, June 2010 to May 2012.

<p>Among inpatients, the incidence of <i>Clostridium difficile</i> infection was highest in the period 3 to 14 days after the start of antibiotic therapy, during antibiotic therapy, and within 5 days of the end of antibiotic therapy. * Includes patients without any identified antibiotic use.</p

Timing and Magnitude of CDI Risk Associated with Antibiotic Exposures.

<p>Abbreviations: AIC, Akaike's Information Criterion; CDI, <i>Clostridium difficile</i> infection; CI, confidence interval; d, days; IR, incidence rate; IRR, incidence rate ratio.</p>a<p>Incidence rate, per 10,000 patient-days.</p>b<p>The difference in AIC relative to the reference model (current antibiotic use): negative numbers denote an improvement in fit. Δ AIC <−2 was considered a statistically significant improvement in fit at p<0.05.</p>c<p>Adjusted for time since hospital admission, age, sex, number of previous hospital admissions, infection pressure, and current or prior ICU admission.</p><p>Timing and Magnitude of CDI Risk Associated with Antibiotic Exposures.</p

CDI Risk Associated with Antimicrobial Exposures During and Within 5 days of the End of Antimicrobial Therapy, for Antibiotic Risk Indexes and Specific Antibiotic Exposures.

<p>Abbreviations: AIC, Akaike's Information Criterion; CDI, <i>Clostridium difficile</i> infection; CI, confidence interval; d, days; IR, incidence rate; IRR, incidence rate ratio.</p>a<p>Incidence rate, per 10,000 patient-days.</p>b<p>The difference in AIC relative to the reference model (receipt of any antibiotic in the previous 5 days): negative numbers denote an improvement in fit. Δ AIC <−2 was considered a statistically significant improvement in fit at p<0.05.</p>c<p>Adjusted for time since hospital admission, age, sex, number of previous hospital admissions, infection pressure, and current or prior ICU admission.</p>d<p>Each antibiotic group was assessed in a separate model; the reference group for each model was no receipt of antibiotics in the last 5 days.</p><p>CDI Risk Associated with Antimicrobial Exposures During and Within 5 days of the End of Antimicrobial Therapy, for Antibiotic Risk Indexes and Specific Antibiotic Exposures.</p

Additional file 1: of Differential outcome of an antimicrobial stewardship audit and feedback program in two intensive care units: a controlled interrupted time series study

Antimicrobials Included in Overall Antimicrobial Use and Cost. Antimicrobials Included in Overall Antimicrobial Use and Cost (PDF 206 kb

Reduced rates of <i>C. difficile</i> infection associated with the introduction of public reporting.

<p>Observed monthly rates of <i>C. difficile</i> infection in Ontario (solid blue line) were generally increasing prior to the introduction of public reporting in September 2008 (identified by black dotted line), and declined after this intervention. Post-intervention rates were significantly lower than rates predicted by a Poisson model (red dashed line) derived from pre-intervention data points and adjusted for age and hospital strata, and overall burden of community antibiotic use (with 0- to 12-mo lags).</p

Tracer analyses evaluating longitudinal time trends of infections not expected to be impacted by hospital public reporting of <i>C. difficile</i> infection rates.

<p>Neither community-acquired bacterial gastrointestinal infections (A) nor urinary tract infections (B) exhibited a change in incidence concurrent with the introduction of <i>C. difficile</i> infection public reporting in September 2008.</p