# Association Between Antimicrobials and Pump Proton Inhibitors Consumption with the Incidence of Nosocomial Clostridiodes difficile Infection in High Complexity Hospitals in Costa Rica

## TL;DR

This study examines how antimicrobial and PPI use in Costa Rican hospitals relates to the occurrence of Clostridiodes difficile infections over five years.

## Contribution

The study identifies specific antimicrobials associated with CDI and evaluates the impact of key events like the pandemic and ASP implementation.

## Key findings

- Clindamycin, cephalosporins, and macrolides showed a positive association with CDI despite decreasing use.
- PPI consumption remained stable and was not linked to CDI incidence.
- Key events like the pandemic and ASP implementation had no significant impact on CDI rates.

## Abstract

Background: Exposure to antimicrobials and Proton Pump Inhibitors (PPIs) are modifiable risk factors for nosocomial Clostridiodes difficile infection (CDI). We investigated the association between these agents and nosocomial CDI over five years. Methods: Nosocomial CDI from January 2017 to December 2021 were included. Consumption trends were analyzed using a simple linear regression model. A correlation analysis was performed using Spearman’s test in two ways: without a time interval and with 1-month interval matching. An interrupted time-series method to evaluate the impact of three key temporal breakpoints on CDI incidence rate was performed using the Poisson regression model. Results: A downward trend for cephalexin, ceftriaxone, clindamycin, gentamicin, macrolides, metronidazole, and penicillin sodium was identified. In contrast, an upward trend was recognized for amoxicillin, ceftazidime/avibactam, ertapenem, fluconazole, ketoconazole, levofloxacin, and tigecycline. Among the antimicrobials that showed a positive association between consumption and the incidence of CDI are clindamycin and cephalosporins after immediate consumption. Moreover, macrolides and metronidazole presented a positive correlation, in both immediate and delayed consumption. PPIs consumption did not show changes and was not associated with nosocomial CDI incidence. The interrupted time series analysis showed no changes at the breakpoints selected. Conclusions: Consumption of clindamycin, cephalosporins, and macrolides showed positive association with CDI, despite having a downtrend in consumption. Specific events, such as the COVID-19 pandemic and the implementation of ASP, have had no correlation with CDI. Further analysis is required in Latin America to advance our understanding of risk factors associated with CDI.