title: Effect of antibiotic stewardship programmes on Clostridium difficile incidence: a systematic review and meta-analysis.
abstract: OBJECTIVE
  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 I(2) 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.
authors.affiliation: Carver College of Medicine, University of Iowa, Iowa City, IA, USA.
authors.forename: Leah M
authors.initials: LM
authors.lastname: Feazel
authors.affiliation: Carver College of Medicine, University of Iowa, Iowa City, IA, USA The Center for Comprehensive Access and Delivery Research and Evaluation (CADRE), Iowa City VA Health Care System, Iowa City, IA, USA.
authors.forename: Ashish
authors.initials: A
authors.lastname: Malhotra
authors.affiliation: Carver College of Medicine, University of Iowa, Iowa City, IA, USA The Center for Comprehensive Access and Delivery Research and Evaluation (CADRE), Iowa City VA Health Care System, Iowa City, IA, USA.
authors.forename: Eli N
authors.initials: EN
authors.lastname: Perencevich
authors.affiliation: Carver College of Medicine, University of Iowa, Iowa City, IA, USA The Center for Comprehensive Access and Delivery Research and Evaluation (CADRE), Iowa City VA Health Care System, Iowa City, IA, USA.
authors.forename: Peter
authors.initials: P
authors.lastname: Kaboli
authors.affiliation: Carver College of Medicine, University of Iowa, Iowa City, IA, USA.
authors.forename: Daniel J
authors.initials: DJ
authors.lastname: Diekema
authors.affiliation: Carver College of Medicine, University of Iowa, Iowa City, IA, USA The Center for Comprehensive Access and Delivery Research and Evaluation (CADRE), Iowa City VA Health Care System, Iowa City, IA, USA marin-schweizer@uiowa.edu.
authors.forename: Marin L
authors.initials: ML
authors.lastname: Schweizer
mesh_terms: D000328:Adult; D000900:Anti-Bacterial Agents / Q000627:therapeutic use*; D016360:Clostridioides difficile / Q000302:isolation & purification*; D003015:Clostridium Infections / Q000453:epidemiology* / Q000382:microbiology / Q000517:prevention & control; D003428:Cross Infection / Q000453:epidemiology* / Q000382:microbiology / Q000517:prevention & control; D011307:Drug Prescriptions / Q000592:standards*; D004363:Drug Utilization / Q000592:standards*; D006801:Humans; D015994:Incidence
chemical_list: D000900:Anti-Bacterial Agents
keywords: antibiotic restriction; geriatrics; healthcare-associated infections