Approaching zero: temporal effects of a restrictive antibiotic policy on hospital-acquired Clostridium difficile, extended-spectrum β-lactamase-producing coliforms and meticillin-resistant Staphylococcus aureus

Int J Antimicrob Agents. 2013 Feb;41(2):137-42. doi: 10.1016/j.ijantimicag.2012.10.013. Epub 2012 Dec 28.


A restrictive antibiotic policy banning routine use of ceftriaxone and ciprofloxacin was implemented in a 450-bed district general hospital following an educational campaign. Monthly consumption of nine antibiotics was monitored in defined daily doses (DDDs) per 1000 patient-occupied bed-days (1000 pt-bds) 9 months before until 16 months after policy introduction. Hospital-acquired Clostridium difficile, meticillin-resistant Staphylococcus aureus (MRSA) and extended-spectrum β-lactamase (ESBL)-producing coliform cases per month/1000 pt-bds were identified and reviewed throughout the hospital. Between the first and final 6 months of the study, average monthly consumption of ceftriaxone reduced by 95% (from 46.213 to 2.129 DDDs/1000 pt-bds) and that for ciprofloxacin by 72.5% (109.804 to 30.205 DDDs/1000 pt-bds). Over the same periods, hospital-acquisition rates for C. difficile reduced by 77% (2.398 to 0.549 cases/1000 pt-bds), for MRSA by 25% (1.187 to 0.894 cases/1000 pt-bds) and for ESBL-producing coliforms by 17% (1.480 to 1.224 cases/1000 pt-bds). Time-lag modelling confirmed significant associations between ceftriaxone and C. difficile cases at 1 month (correlation 0.83; P<0.005), and between ciprofloxacin and ESBL-producing coliform cases at 2 months (correlation 0.649; P=0.002). An audit performed 3 years after the policy showed sustained reduction in C. difficile rates (0.259 cases/1000 pt-bds), with additional decreases for MRSA (0.409 cases/1000 pt-bds) and ESBL-producing coliforms (0.809 cases/1000 pt-bds). In conclusion, banning two antibiotics resulted in an immediate and profound reduction in hospital-acquired C. difficile, with possible longer-term effects on MRSA and ESBL-producing coliform rates. Antibiotic stewardship is fundamental in the control of major hospital pathogens.

MeSH terms

  • Adult
  • Aged
  • Aged, 80 and over
  • Anti-Bacterial Agents / therapeutic use*
  • Bacterial Infections / epidemiology
  • Bacterial Infections / microbiology
  • Ceftriaxone / therapeutic use
  • Ciprofloxacin / therapeutic use
  • Clostridioides difficile / drug effects*
  • Clostridioides difficile / isolation & purification
  • Cross Infection / epidemiology
  • Cross Infection / microbiology*
  • Drug Resistance, Bacterial*
  • Drug Utilization / standards*
  • Drug Utilization / statistics & numerical data
  • Enterobacteriaceae / drug effects*
  • Enterobacteriaceae / isolation & purification
  • Female
  • Humans
  • Incidence
  • Male
  • Methicillin-Resistant Staphylococcus aureus / drug effects*
  • Methicillin-Resistant Staphylococcus aureus / isolation & purification
  • Middle Aged
  • Organizational Policy
  • Time Factors


  • Anti-Bacterial Agents
  • Ciprofloxacin
  • Ceftriaxone