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Hospital-wide Restriction of Clindamycin: Effect on the Incidence of Clostridium difficile-Associated Diarrhea and Cost

Michael W. Climo, MD; Debra S. Israel, PharmD; Edward S. Wong, MD; Denise Williams; Philip Coudron, PhD; and Sheldon M. Markowitz, MD
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From Hunter Holmes McGuire Veterans Affairs Medical Center, Medical College of Virginia, and Virginia Commonwealth University, Richmond, Virginia. Acknowledgments: The authors thank Pat Carlson, PhD, for technical assistance and Dolores Grub for gathering hospital pharmacy cost data. Requests for Reprints: Michael Climo, MD, Hunter Holmes McGuire Veterans Affairs Medical Center, 1201 Broad Rock Boulevard, Section 111C, Richmond, VA 23249. Current Author Addresses: Drs. Climo, Wong, and Williams: Hunter Holmes McGuire Veterans Affairs Medical Center, 1201 Broad Rock Boulevard, Section 111C, Richmond, VA 23249.

Copyright ©2004 by the American College of Physicians

Ann Intern Med. 1998;128(12_Part_1):989-995. doi:10.7326/0003-4819-128-12_Part_1-199806150-00005
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Background: Widespread antibiotic use has been associated with increases in both bacterial resistance and nosocomial infection.

Objective: To characterize the impact of hospital-wide clindamycin restriction on the incidence of Clostridium difficile-associated diarrhea and on antimicrobial prescribing practices.

Design: Prospective, observational cohort study.

Setting: University-affiliated Veterans Affairs Medical Center.

Patients: Hospitalized patients with symptomatic diarrhea.

Measurements: Clinical data on individual patients and data on antibiotic use were obtained from hospital pharmacy records. Hospital-wide use of antimicrobial agents was monitored. Isolates of C. difficile underwent antimicrobial susceptibility testing and molecular typing.

Results: An outbreak of C. difficile-associated diarrhea was caused by a clonal isolate of clindamycin-resistant C. difficile and was associated with increased use of clindamycin. Hospital-wide requirement of approval by an infectious disease consultant of clindamycin use led to an overall reduction in clindamycin use, a sustained reduction in the mean number of cases of C. difficile-associated diarrhea (11.5 cases/month compared with 3.33 cases/month; P < 0.001), and an increase in clindamycin susceptibility among C. difficile isolates (9% compared with 61%; P < 0.001). A parallel increase was noted in the use of and costs associated with other antibiotics with antianaerobic activity, including cefotetan, ticarcillin-clavulanate, and imipenem-cilastin. The hospital realized overall cost savings as a result of the decreased incidence of C. difficile-associated diarrhea.

Conclusions: Hospital formulary restriction of clindamycin is an effective way to decrease the number of infections due to C. difficile. It can also lead to a return in clindamycin susceptibility among isolates and can effect cost savings to the hospital.


Grahic Jump Location
Figure 1.
Cases of Clostridium difficile-associated diarrhea, reported by quarter.C. difficile

Hospital-wide restriction of clindamycin began in March 1994. The horizontal bars above the graph indicate periods during which antimicrobial susceptibility testing was done on isolates; the frequency of clindamycin resistance is shown above the bars.

Grahic Jump Location
Grahic Jump Location
Figure 2.
Antimicrobial resistance among Clostridium difficile isolates collected between 1987 and 1996.

The percentage of isolates resistant to clindamycin, metronidazole, and vancomycin was determined by using the agar dilution method for nosocomial isolates collected from hospitalized patients over four separate time periods before and after the hospital-wide restriction of clindamycin began in March 1994.

Grahic Jump Location
Grahic Jump Location
Figure 3.
Comparison of pharmacy costs, 1992 to 1996.

Acquisition costs for the seven antimicrobial agents with anaerobic activity were collected from hospital pharmacy records. Totals for each year are shown on the right. Clindamycin restriction began in March 1994.

Grahic Jump Location




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