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Author Notes:

Correspondence: Raymund Dantes, MD, MPH, Epidemic Intelligence Service Officer, Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, 1600 Clifton Road, NE, Mailstop A-31, Atlanta, GA 30333 (vic5@cdc.gov)

We acknowledge the following individuals for their contributions with implementation of surveillance and collection of data: Joelle Nadle, MPH, Erin Garcia, MPH, and Erin Parker, MPH (California Emerging Infections Program); Wendy Bamberg, MD and Helen Johnston, MPH (Colorado Emerging Infections Program); Carol Lyons, MPH (Connecticut Emerging Infections Program); Olivia Almendares, MPH, Leigh Ann Clark, MPH, Andrew Revis, MPH, and Zirka Thompson, MPH (Georgia Emerging Infections Program); Rebecca Perlmutter, MPH (Maryland Emerging Infections Program); Ruth Lynfield, MD (Minnesota Emerging Infections Program); Nathan Blacker (New Mexico Emerging Infections Program); Rebecca Tsay, MPH, Deborah Nelson, RN (New York Emerging Infections Program); Valerie Ocampo, RN, IMPH (Oregon Emerging Infections Program); Rebecca Roberts, MS (Respiratory Diseases Branch, Centers for Disease Control and Prevention [CDC], Atlanta, GA); and Robert Hunkler (IMS Health).

The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the CDC.

The interpretation and reporting of these data are the responsibility of the authors and in no way should be seen as an official policy of the US government.

Potential conflicts of interest. All authors: No reported conflicts.

All authors have submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest.


Research Funding:

This work was supported by the Centers for Disease Control and Prevention Emerging Infections Program and the National Center for National Center for Emerging and Zoonotic Infectious Diseases.


  • Science & Technology
  • Life Sciences & Biomedicine
  • Infectious Diseases
  • antibacterial agents
  • Clostridium difficile
  • epidemiology
  • outpatients
  • public health surveillance

Association Between Outpatient Antibiotic Prescribing Practices and Community-Associated Clostridium difficile Infection

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Journal Title:

Open Forum Infectious Diseases


Volume 2, Number 3


, Pages ofv113-ofv113

Type of Work:

Article | Final Publisher PDF


Background.  Antibiotic use predisposes patients to Clostridium difficile infections (CDI), and approximately 32% of these infections are community-associated (CA) CDI. The population-level impact of antibiotic use on adult CA-CDI rates is not well described. Methods.  We used 2011 active population- and laboratory-based surveillance data from 9 US geographic locations to identify adult CA-CDI cases, defined as C difficile-positive stool specimens (by toxin or molecular assay) collected from outpatients or from patients ≤3 days after hospital admission. All patients were surveillance area residents and aged ≥20 years with no positive test ≤8 weeks prior and no overnight stay in a healthcare facility ≤12 weeks prior. Outpatient oral antibiotic prescriptions dispensed in 2010 were obtained from the IMS Health Xponent database. Regression models examined the association between outpatient antibiotic prescribing and adult CA-CDI rates. Methods.  Healthcare providers prescribed 5.2 million courses of antibiotics among adults in the surveillance population in 2010, for an average of 0.73 per person. Across surveillance sites, antibiotic prescription rates (0.50-0.88 prescriptions per capita) and unadjusted CA-CDI rates (40.7-139.3 cases per 100 000 persons) varied. In regression modeling, reducing antibiotic prescribing rates by 10% among persons ≥20 years old was associated with a 17% (95% confidence interval, 6.0%-26.3%; P = .032) decrease in CA-CDI rates after adjusting for age, gender, race, and type of diagnostic assay. Reductions in prescribing penicillins and amoxicillin/clavulanic acid were associated with the greatest decreases in CA-CDI rates. Conclusions and Relevance.  Community-associated CDI prevention should include reducing unnecessary outpatient antibiotic use. A modest reduction of 10% in outpatient antibiotic prescribing can have a disproportionate impact on reducing CA-CDI rates.

Copyright information:

Copyright Published by Oxford University Press on behalf of the Infectious Diseases Society of America 2015. This work is written by (a) US Government employee(s) and is in the public domain in the US.

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