Incidence of Clostridioides difficile infection (CDI) related to antibiotic prescribing by GP surgeries in Wales

Florence Tydeman, Noel Craine, Kimberley Kavanagh, Helen Adams, Rosy Reynolds, Victoria McClure, Harriet Hughes, Matt Hickman, Chris Robertson

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Clostridioides difficile infection (CDI) is a healthcare-acquired infection (HAI) causing significant morbidity and mortality. Welsh CDI rates are high in comparison with those in England and Scotland.

This retrospective ecological study used aggregated disease surveillance data to understand the impact of total and high-risk Welsh GP antibiotic prescribing on total and stratified inpatient/non-inpatient CDI incidence.

All cases of confirmed CDI, during the financial years 2014–15 to 2017–18, were linked to aggregated rates of antibiotic prescribing in their GP surgery and classified as ‘inpatient’, ‘non-inpatient’ or ‘unknown’ by Public Health Wales. Multivariable negative-binomial regression models, comparing CDI incidence with antibiotic prescribing rates, were adjusted for potential confounders: location; age; social deprivation; comorbidities (estimated from prevalence of key health indicators) and proton pump inhibitor (PPI) prescription rates.

There were 4613 confirmed CDI cases, with an incidence (95% CI) of 1.44 (1.40–1.48) per 1000 registered patients. Unadjusted analysis showed that an increased risk of total CDI incidence was associated with higher total antibiotic prescribing [relative risk (RR) (95% CI) = 1.338 (1.170–1.529) per 1000 items per 1000 specific therapeutic group age-sex related GP prescribing units (STAR-PU)] and that high-risk antibiotic classes were positively associated with total CDI incidence. Location, age ≥65 years and diabetes were associated with increased risk of CDI. After adjusting for confounders, prescribing of clindamycin showed a positive association with total CDI incidence [RR (95% CI) = 1.079 (1.001–1.162) log items per 1000 registered patients].

An increased risk of CDI is demonstrated at a primary care practice population level, reflecting their antibiotic prescribing rates, particularly clindamycin, and population demographics.
Original languageEnglish
Article numberdkab204
Pages (from-to)2437-2445
Number of pages9
JournalJournal of Antimicrobial Chemotherapy
Issue number9
Early online date21 Jun 2021
Publication statusPublished - 1 Sep 2021


  • clostridioides difficile infection
  • antibiotic prescribing
  • Welsh CDI rates


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