Starr and colleagues (Feb 8, p 425)1
suggest a possible strategy to control Clostridium difficile
infection—namely, by reducing the duration of antimicrobial therapy C difficile
infections should fall. We attempted this approach unsuccessfully.
We have shown that cefuroxime use in our hospital was associated with C difficile
infection with a resultant increase in hospital stay.2
In early 1996 we reviewed at the bedside medical patients who had received antimicrobials for more than 2 days and compared our intervention with a historical control group. For the intervention group we suggested ways in which patient management could be modified to exclude intravenous antimicrobials, especially broadspectrumβ-lactams. Our advice was taken within 24 h in most patients, but we were unable to reduce the duration of intravenous (iv) therapy (mean 6·0 days intervention, 5·7 days control) or rate of C difficile
infection (27% intervention, 22% control) for those with chest infection. We concluded that in most cases in our hospital iv cefuroxime was being given for an appropriate time for the clinical situation. This conclusion, in conjunction with the continuing high frequency of C difficile
infection in our medical patients, led to a change in our antimicrobial guidelines to replace cephalosporins with drugs less likely to be associated with C difficile
-ie, fluoroquinolones. In practice we changed our protocol for treatment of chest infection from one using clarithromycin and cefuroxime to a combination of clarithromycin, penicillin, and ciprofloxacin. In the 9 months following the change in antibiotic protocols for chest infection, the number of cases of C difficile
infection fell by 40% (table
). Mortality and length of stay were unchanged.