Effect of antibiotic stewardship programmes on Clostridium difficile incidence: A systematic review and meta-analysis

Leah M. Feazel, Ashish Malhotra, Eli N. Perencevich, Peter Kaboli, Daniel J. Diekema, Marin L. Schweizer

Research output: Contribution to journalReview articlepeer-review

206 Scopus citations


Objectives: Despite vigorous infection control measures, Clostridium difficile continues to cause significant disease burden. Antibiotic stewardship programmes (ASPs) may prevent C. difficile infections by limiting exposure to certain antibiotics. Our objective was to perform a meta-analysis of published studies to assess the effect of ASPs on the risk of C. difficile infection in hospitalized adult patients. Methods: Searches of PubMed, Web of Science, Cumulative Index to Nursing and Allied Health Literature and two Cochrane databases were conducted to find all published studies on interventions related to antibiotic stewardship and C. difficile. Two investigators independently assessed study eligibility and extracted data. Risk of bias was assessed using the Downs and Black tool. Risk ratios were pooled using random effects models. Heterogeneity was evaluated using the I2 statistic. Results: The final search yielded 891 articles; 78 full articles were reviewed and 16 articles were identified for inclusion. Included articles used quasi-experimental (interrupted time series or before-after) or observational (case-control) study designs. When the results of all studies were pooled in a random effects model, a significant protective effect (pooled risk ratio 0.48; 95% CI: 0.38, 0.62) was observed between ASPs and C. difficile incidence. When stratified by intervention type, a significant effect was found for restrictive ASPs (complete removal of drug or prior approval requirement). Furthermore, ASPs were particularly effective in geriatric settings. Conclusions: Restrictive ASPs can be used to reduce the risk of C. difficile infection. Published by Oxford University Press on behalf of the British Society for Antimicrobial Chemotherapy 2014. This work is written by US Government employees and is in the public domain in the US.

Original languageEnglish (US)
Article numberdku046
Pages (from-to)1748-1754
Number of pages7
JournalJournal of Antimicrobial Chemotherapy
Issue number7
StatePublished - Jul 2014
Externally publishedYes


  • Antibiotic restriction
  • Geriatrics
  • Healthcare-associated infections


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