TY - JOUR T1 - Respiratory antibiotic use and <em>Clostridium difficile</em> infection: is it the drugs or is it the doctors? JF - Thorax JO - Thorax SP - 633 LP - 634 DO - 10.1136/thorax.55.8.633 VL - 55 IS - 8 AU - M H WILCOX Y1 - 2000/08/01 UR - http://thorax.bmj.com/content/55/8/633.abstract N2 - The 1990s have seen Clostridium difficile infection (CDI) rise to prominence (fig1).1-3 Why has this occurred? Proposed explanations include spread of virulent strains, increased patient carriage of C difficile, and suboptimal hospital cleaning leading to increased environmental contamination by clostridial spores.1 However, given the inextricable link between antibiotic exposure and CDI, increased antimicrobial prescribing in general and/or use of high risk agents must be considered as the main impetus for the rising reports of CDI. The association between cephalosporin use—notably second and, particularly, third generation agents such as cefuroxime and cefotaxime—and CDI is well described.4-9 British Thoracic Society (BTS) guidelines for the treatment of community acquired pneumonia (CAP) were published in 199310 and recommended the use of second or third generation cephalosporins for severe cases. It has been suggested that these guidelines were responsible for increased cephalosporin prescribing and, as a result, fuelled the increased incidence of CDI.5 ,8 ,11 ,12However, as shown in fig 2, cephalosporin sales to British hospitals have been relatively stable in recent years,13 although such analyses may mask prescribing patterns in patients at high risk of CDI, particularly the elderly. Furthermore, reports of CDI were already increasing before the publication of the BTS guidelines on CAP (fig 1). Nevertheless, individual units have reported increased cephalosporin prescribing (at the very least) coincident with the 1993 guidelines.11 Such observations may reflect inappropriate interpretation and/or implementation of the guidelines—for example, overclassification of CAP cases as “severe” rather than “mild/moderate”.Figure 1 Laboratory reports of C difficile to Communicable Disease Surveillance Centre (England and Wales) 1982–98.Figure 2 Antibiotic sales into UK hospitals. (Note: a change in data collection … ER -