Effects of fluoroquinolone restriction (from 2007 to 2012) on Clostridium difficile infections: interrupted time-series analysis

J Hosp Infect. 2015 Sep;91(1):74-80. doi: 10.1016/j.jhin.2015.05.013. Epub 2015 Jun 21.


Background: Antimicrobial stewardship is a key component in the reduction of healthcare-associated infections, particularly Clostridium difficile infection (CDI). We successfully restricted the use of cephalosporins and, subsequently, fluoroquinolones. From an endemically high level of >280 cases per year in 2007-08, the number of CDIs reduced to 72 cases in 2011-12.

Aim: To describe the implementation and impact of fluoroquinolone restriction on CDI.

Methods: This was an interrupted time-series analysis pre and post fluoroquinolone restriction for 60 months based on a Poisson distribution model.

Findings: In June 2008, fluoroquinolone consumption halved to about 5 defined daily doses (DDD) per 100 occupied bed-days (OBD). This was followed by a significant fall in CDI number [rate ratio (RR): 0.332; 95% confidence interval (CI): 0.240-0.460] which remained low over the subsequent months. Subsequently, fluoroquinolone consumption was further reduced to about 2 DDD/100 OBD in June 2010 accompanied by further reduction in CDI rate (RR: 0.394; 95% CI: 0.199-0.781). In a univariate Poisson model the CDI rate was associated with fluoroquinolone usage (RR: 1.086; 95% CI: 1.077-1.094).

Conclusion: We conclude that in an environment where cephalosporin usage is already low, the reduction in fluoroquinolone usage was associated with an immediate, large, and significant reduction in CDI cases.

Keywords: Antimicrobial stewardship; Clostridium difficile; Fluoroquinolones; Interrupted time-series analysis.

MeSH terms

  • Aged
  • Aged, 80 and over
  • Anti-Bacterial Agents / pharmacology*
  • Cephalosporins / pharmacology
  • Clostridioides difficile / drug effects*
  • Clostridium Infections / drug therapy
  • Clostridium Infections / epidemiology
  • Clostridium Infections / microbiology*
  • Cross Infection / drug therapy
  • Cross Infection / epidemiology
  • Cross Infection / microbiology
  • Drug Utilization / trends
  • Female
  • Fluoroquinolones / pharmacology*
  • Humans
  • Infection Control / methods
  • Interrupted Time Series Analysis / methods
  • Male
  • Ribotyping / methods


  • Anti-Bacterial Agents
  • Cephalosporins
  • Fluoroquinolones