Evaluation of the US Food and Drug Administration sentinel analysis tools in confirming previously observed drug-outcome associations: The case of clindamycin and Clostridium difficile infection

Pharmacoepidemiol Drug Saf. 2018 Jul;27(7):731-739. doi: 10.1002/pds.4420. Epub 2018 Mar 13.


Purpose: The Food and Drug Administration's Sentinel System developed parameterized, reusable analytic programs for evaluation of medical product safety. Research on outpatient antibiotic exposures, and Clostridium difficile infection (CDI) with non-user reference groups led us to expect a higher rate of CDI among outpatient clindamycin users vs penicillin users. We evaluated the ability of the Cohort Identification and Descriptive Analysis and Propensity Score Matching tools to identify a higher rate of CDI among clindamycin users.

Methods: We matched new users of outpatient dispensings of oral clindamycin or penicillin from 13 Data Partners 1:1 on propensity score and followed them for up to 60 days for development of CDI. We used Cox proportional hazards regression stratified by Data Partner and matched pair to compare CDI incidence.

Results: Propensity score models at 3 Data Partners had convergence warnings and a limited range of predicted values. We excluded these Data Partners despite adequate covariate balance after matching. From the 10 Data Partners where these models converged without warnings, we identified 807 919 new clindamycin users and 8 815 441 new penicillin users eligible for the analysis. The stratified analysis of 807 769 matched pairs included 840 events among clindamycin users and 290 among penicillin users (hazard ratio 2.90, 95% confidence interval 2.53, 3.31).

Conclusions: This evaluation produced an expected result and identified several potential enhancements to the Propensity Score Matching tool. This study has important limitations. CDI risk may have been related to factors other than the inherent properties of the drugs, such as duration of use or subsequent exposures.

Keywords: Clostridium difficile; United States Food and Drug Administration; clindamycin; penicillins; pharmacoepidemiology; postmarketing; product surveillance.

Publication types

  • Evaluation Study
  • Research Support, U.S. Gov't, P.H.S.

MeSH terms

  • Adverse Drug Reaction Reporting Systems*
  • Anti-Bacterial Agents / administration & dosage
  • Anti-Bacterial Agents / adverse effects*
  • Clindamycin / administration & dosage
  • Clindamycin / adverse effects*
  • Clostridioides difficile*
  • Clostridium Infections / epidemiology
  • Clostridium Infections / etiology*
  • Clostridium Infections / microbiology
  • Humans
  • Risk Factors
  • Sentinel Surveillance*
  • United States / epidemiology
  • United States Food and Drug Administration


  • Anti-Bacterial Agents
  • Clindamycin