title: Management of a cluster ofClostridium difficileinfections among patients with osteoarticular infections.
abstract: BACKGROUND
  Here we describe a cluster of hospital-acquiredClostridium difficileinfections (CDI) among 26 patients with osteoarticular infections. The aim of the study was to define the source ofC. difficileand to evaluate the impact of general infection control measures and antibiotic stewardship on the incidence of CDI.
  
  
  METHODS
  Epidemiological analysis included typing ofC. difficilestrains and analysis of possible patient to patient transmission. Infection control measures comprised strict isolation of CDI patients, additional hand washings, and intensified environmental cleaning with sporicidal disinfection. In addition an antibiotic stewardship program was implemented in order to prevent the use of CDI high risk antimicrobials such as fluoroquinolones, clindamycin, and cephalosporins.
  
  
  RESULTS
  The majority of CDI (n= 15) were caused byC. difficileribotype 027 (RT027). Most RT027 isolates (n= 9) showed high minimal inhibitory concentrations (MIC) for levofloxacin, clindamycin, and remarkably to rifampicin, which were all used for the treatment of osteoarticular infections. Epidemiological analysis, however, revealed no closer genetic relationship among the majority of RT027 isolates. The incidence of CDI was reduced only when a significant reduction in the use of fluoroquinolones (p= 0.006), third generation cephalosporins (p= 0.015), and clindamycin (p= 0.001) was achieved after implementation of an intensified antibiotic stewardship program which included a systematic review of all antibiotic prescriptions.
  
  
  CONCLUSIONS
  The successful reduction of the CDI incidence demonstrates the importance of antibiotic stewardship programs focused on patients treated for osteoarticular infections.
authors.affiliation: Institute of Medical Microbiology, Infection Control and Prevention, Otto-von-Guericke University of Magdeburg, Leipziger Straße 44, 39120 Magdeburg, Germany.
authors.forename: Jacqueline
authors.initials: J
authors.lastname: Färber
authors.affiliation: Department of Orthopedic Surgery, Otto-von-Guericke University of Magdeburg, Magdeburg, Germany.
authors.forename: Sebastian
authors.initials: S
authors.lastname: Illiger
authors.affiliation: Institute of Medical Microbiology and Hygiene, Consultant Laboratory for Clostridium difficile, University of Saarland, Saarland, Germany.
authors.forename: Fabian
authors.initials: F
authors.lastname: Berger
authors.affiliation: Institute of Medical Microbiology and Hygiene, Consultant Laboratory for Clostridium difficile, University of Saarland, Saarland, Germany.
authors.forename: Barbara
authors.initials: B
authors.lastname: Gärtner
authors.affiliation: Institute for Laboratory Medicine, Microbiology and Hygiene, Christophorus Kliniken, Coesfeld, Germany.
authors.forename: Lutz
authors.initials: L
authors.lastname: von Müller
authors.affiliation: Department of Orthopedic Surgery, Otto-von-Guericke University of Magdeburg, Magdeburg, Germany.
authors.forename: Christoph H
authors.initials: CH
authors.lastname: Lohmann
authors.affiliation: Institute of Medical Microbiology, Infection Control and Prevention, Otto-von-Guericke University of Magdeburg, Leipziger Straße 44, 39120 Magdeburg, Germany.
authors.forename: Katja
authors.initials: K
authors.lastname: Bauer
authors.affiliation: Central pharmacy, Otto-von-Guericke University of Magdeburg, Magdeburg, Germany.
authors.forename: Christina
authors.initials: C
authors.lastname: Grabau
authors.affiliation: Central pharmacy, Otto-von-Guericke University of Magdeburg, Magdeburg, Germany.
authors.forename: Stefanie
authors.initials: S
authors.lastname: Zibolka
authors.affiliation: Institute of Medical Microbiology, Infection Control and Prevention, Otto-von-Guericke University of Magdeburg, Leipziger Straße 44, 39120 Magdeburg, Germany.|Organ-specific Immune Regulation, Helmholtz Centre for Infection Research, Braunschweig, Germany.
authors.forename: Dirk
authors.initials: D
authors.lastname: Schlüter
authors.affiliation: Institute of Medical Microbiology, Infection Control and Prevention, Otto-von-Guericke University of Magdeburg, Leipziger Straße 44, 39120 Magdeburg, Germany.
authors.forename: Gernot
authors.initials: G
authors.lastname: Geginat
keywords: Antibiotic stewardship; C. difficile; Osteoarticular infections; Ribotype 027; Rifampicin