Evidence map›Paper›PMID 28130063›Full record

Observational studyThe Lancet. Infectious diseases2017

Effects of control interventions on Clostridium difficile infection in England: an observational study.

Kate E Dingle, Xavier Didelot, T Phuong Quan, David W Eyre, Nicole Stoesser, Tanya Golubchik, Rosalind M Harding, Daniel J Wilson, David Griffiths, Alison Vaughan and 19 more

Abstract readObservational Study
PubMed Full text at PMC Publisher
In one paragraph

Observational study in The Lancet. Infectious diseases, 2017. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Cited by 147 papers, 4 of them syntheses that pooled it.

0numbers the graph read from it
0cells of the map it votes in
147citing papers in PubMed, 4 pooled it
–field-weighted citation impact
1 · What the graph read from it

What it found

Each row is one number read from the abstract, on the scale the paper reported it, with its interval. Left of the dashed line favours the treatment, right favours the comparator. Under each row is the sentence it came from. New to these charts? A ten-minute tutorial.

The abstract states no effect estimate the extractor could read, or names no intervention and outcome on the map, so this paper lights no cell and moves no belief. It is still indexed, cited and linked below.

2 · The registry

The trial behind it

Trials whose registry record cites this paper, or whose number appears in the abstract. A trial that started after this paper was published is citing it as background, not reporting it.

Neither the registry nor the abstract names a trial number. If this is a trial report, that itself is worth knowing.

3 · Its place in the literature

Who cites it

147 citing papers in PubMed, 4 syntheses or guidelines pooled it.

  1. Pooled it
  2. Pooled it
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  4. A systematic review of randomised clinical trials for oral antibiotic treatment of acute pyelonephritis.European journal of clinical microbiology & infectious diseases : official publication of the European Society of Clinical Microbiology · 2018
    Pooled it
  5. Review
  6. Article
  7. Review
  8. The PRECISE framework: a structured approach to antibiogram interpretation for antimicrobial optimization at the bedside.Revista espanola de quimioterapia : publicacion oficial de la Sociedad Espanola de Quimioterapia · 2026
    Review
  9. Factors driving increases inEuro surveillance : bulletin Europeen sur les maladies transmissibles = European communicable disease bulletin · 2026
    Article
  10. Article
  11. Article
  12. Epidemiology ofAntibiotics (Basel, Switzerland) · 2026
    Article
  13. Clostridioides difficile pathogenesis and control.Nature reviews. Microbiology · 2026
    Review
  14. Microbiology spectrum · 2026
    Article
  15. Review
  16. Review
  17. Changes in the Epidemiology of Clostridioides difficile Infection.Infectious disease clinics of North America · 2025
    Review
  18. Article
  19. Article
  20. Review

87 more citing papers are in PubMed but not listed here.

4 · The record

Corrections and comments

5 · Who and what money

Authors and funding

29 authors.

Kate E DingleNuffield Department of Clinical Medicine, Oxford University, Oxford, UK; National Institute for Health Research (NIHR) Oxford Biomedical Research Centre, John Radcliffe Hospital, Oxford, UK; NIHR Health Protection Research Unit in Healthcare Associated Infection and Antimicrobial Resistance at University of Oxford in partnership with Public Health England, Oxford, UK. Electronic address: kate.dingle@ndcls.ox.ac.uk.
Xavier DidelotDepartment of Infectious Disease Epidemiology, and NIHR Health Protection Research Unit in Healthcare Associated Infection and Antimicrobial Resistance at Imperial College London in partnership with Public Health England, Imperial College, London, London, UK.
T Phuong QuanNuffield Department of Clinical Medicine, Oxford University, Oxford, UK; National Institute for Health Research (NIHR) Oxford Biomedical Research Centre, John Radcliffe Hospital, Oxford, UK; NIHR Health Protection Research Unit in Healthcare Associated Infection and Antimicrobial Resistance at University of Oxford in partnership with Public Health England, Oxford, UK.
David W EyreNuffield Department of Clinical Medicine, Oxford University, Oxford, UK; National Institute for Health Research (NIHR) Oxford Biomedical Research Centre, John Radcliffe Hospital, Oxford, UK.
Nicole StoesserNuffield Department of Clinical Medicine, Oxford University, Oxford, UK; National Institute for Health Research (NIHR) Oxford Biomedical Research Centre, John Radcliffe Hospital, Oxford, UK.
Tanya GolubchikNuffield Department of Clinical Medicine, Oxford University, Oxford, UK; National Institute for Health Research (NIHR) Oxford Biomedical Research Centre, John Radcliffe Hospital, Oxford, UK.
Rosalind M HardingNational Institute for Health Research (NIHR) Oxford Biomedical Research Centre, John Radcliffe Hospital, Oxford, UK; Department of Zoology, Oxford University, Oxford, UK.
Daniel J WilsonNuffield Department of Clinical Medicine, Oxford University, Oxford, UK; National Institute for Health Research (NIHR) Oxford Biomedical Research Centre, John Radcliffe Hospital, Oxford, UK; Wellcome Trust Centre for Human Genetics, University of Oxford, Oxford, UK.
David GriffithsNuffield Department of Clinical Medicine, Oxford University, Oxford, UK; National Institute for Health Research (NIHR) Oxford Biomedical Research Centre, John Radcliffe Hospital, Oxford, UK.
Alison VaughanNuffield Department of Clinical Medicine, Oxford University, Oxford, UK; National Institute for Health Research (NIHR) Oxford Biomedical Research Centre, John Radcliffe Hospital, Oxford, UK.
John M FinneyNuffield Department of Clinical Medicine, Oxford University, Oxford, UK; National Institute for Health Research (NIHR) Oxford Biomedical Research Centre, John Radcliffe Hospital, Oxford, UK.
David H WyllieNuffield Department of Clinical Medicine, Oxford University, Oxford, UK; National Institute for Health Research (NIHR) Oxford Biomedical Research Centre, John Radcliffe Hospital, Oxford, UK; Public Health England Academic Collaborating Centre, Oxford, UK.
Sarah J OakleyMicrobiology Department, Oxford University Hospitals NHS Trust, Oxford, UK.
Warren N FawleyLeeds Teaching Hospitals and University of Leeds, Department of Microbiology, Leeds General Infirmary, Leeds, UK.
Jane FreemanLeeds Teaching Hospitals and University of Leeds, Department of Microbiology, Leeds General Infirmary, Leeds, UK.
Kirsti MorrisLeeds Teaching Hospitals and University of Leeds, Department of Microbiology, Leeds General Infirmary, Leeds, UK.
Jessica MartinLeeds Teaching Hospitals and University of Leeds, Department of Microbiology, Leeds General Infirmary, Leeds, UK.
Philip HowardLeeds Teaching Hospitals NHS Trust, Leeds, UK.
Sherwood GorbachCubist Pharmaceuticals, Lexington, MA, USA; Tufts University School of Medicine, Boston, MA, USA.
Ellie J C GoldsteinR M Alden Research Laboratory, Culver City, CA USA.
Diane M CitronR M Alden Research Laboratory, Culver City, CA USA.
Susan HopkinsNIHR Health Protection Research Unit in Healthcare Associated Infection and Antimicrobial Resistance at University of Oxford in partnership with Public Health England, Oxford, UK; Healthcare-Associated Infection, Antimicrobial Resistance and Stewardship and Healthcare-Associated Infections Programme, Public Health England, London, UK; Royal Free London NHS Foundation Trust and Public Health England, London, UK.
Russell HopeDepartment of Healthcare-Associated Infections and Antimicrobial Resistance, Centre for Infectious Disease Surveillance and Control, National Infection Service, Public Health England, London, UK.
Alan P JohnsonNIHR Health Protection Research Unit in Healthcare Associated Infection and Antimicrobial Resistance at University of Oxford in partnership with Public Health England, Oxford, UK; Department of Infectious Disease Epidemiology, and NIHR Health Protection Research Unit in Healthcare Associated Infection and Antimicrobial Resistance at Imperial College London in partnership with Public Health England, Imperial College, London, London, UK; Department of Healthcare-Associated Infections and Antimicrobial Resistance, Centre for Infectious Disease Surveillance and Control, National Infection Service, Public Health England, London, UK.
Mark H WilcoxLeeds Teaching Hospitals and University of Leeds, Department of Microbiology, Leeds General Infirmary, Leeds, UK.
Timothy E A PetoNuffield Department of Clinical Medicine, Oxford University, Oxford, UK; National Institute for Health Research (NIHR) Oxford Biomedical Research Centre, John Radcliffe Hospital, Oxford, UK; NIHR Health Protection Research Unit in Healthcare Associated Infection and Antimicrobial Resistance at University of Oxford in partnership with Public Health England, Oxford, UK.
A Sarah WalkerNuffield Department of Clinical Medicine, Oxford University, Oxford, UK; National Institute for Health Research (NIHR) Oxford Biomedical Research Centre, John Radcliffe Hospital, Oxford, UK; NIHR Health Protection Research Unit in Healthcare Associated Infection and Antimicrobial Resistance at University of Oxford in partnership with Public Health England, Oxford, UK.
Derrick W CrookNuffield Department of Clinical Medicine, Oxford University, Oxford, UK; National Institute for Health Research (NIHR) Oxford Biomedical Research Centre, John Radcliffe Hospital, Oxford, UK; NIHR Health Protection Research Unit in Healthcare Associated Infection and Antimicrobial Resistance at University of Oxford in partnership with Public Health England, Oxford, UK.
Modernising Medical Microbiology Informatics Group

Funding

Department of Health DRF-2010-03-40Medical Research Council G0800778Medical Research Council MR/N010760/1Wellcome Trust
6 · The paper itself

Abstract

backgroundThe control of Clostridium difficile infections is an international clinical challenge. The incidence of C difficile in England declined by roughly 80% after 2006, following the implementation of national control policies; we tested two hypotheses to investigate their role in this decline. First, if C difficile infection declines in England were driven by reductions in use of particular antibiotics, then incidence of C difficile infections caused by resistant isolates should decline faster than that caused by susceptible isolates across multiple genotypes. Second, if C difficile infection declines were driven by improvements in hospital infection control, then transmitted (secondary) cases should decline regardless of susceptibility.

methodsRegional (Oxfordshire and Leeds, UK) and national data for the incidence of C difficile infections and antimicrobial prescribing data (1998-2014) were combined with whole genome sequences from 4045 national and international C difficile isolates. Genotype (multilocus sequence type) and fluoroquinolone susceptibility were determined from whole genome sequences. The incidence of C difficile infections caused by fluoroquinolone-resistant and fluoroquinolone-susceptible isolates was estimated with negative-binomial regression, overall and per genotype. Selection and transmission were investigated with phylogenetic analyses.

findingsNational fluoroquinolone and cephalosporin prescribing correlated highly with incidence of C difficile infections (cross-correlations >0·88), by contrast with total antibiotic prescribing (cross-correlations <0·59). Regionally, C difficile decline was driven by elimination of fluoroquinolone-resistant isolates (approximately 67% of Oxfordshire infections in September, 2006, falling to approximately 3% in February, 2013; annual incidence rate ratio 0·52, 95% CI 0·48-0·56 vs fluoroquinolone-susceptible isolates: 1·02, 0·97-1·08). C difficile infections caused by fluoroquinolone-resistant isolates declined in four distinct genotypes (p<0·01). The regions of phylogenies containing fluoroquinolone-resistant isolates were short-branched and geographically structured, consistent with selection and rapid transmission. The importance of fluoroquinolone restriction over infection control was shown by significant declines in inferred secondary (transmitted) cases caused by fluoroquinolone-resistant isolates with or without hospital contact (p<0·0001) versus no change in either group of cases caused by fluoroquinolone-susceptible isolates (p>0·2).

interpretationRestricting fluoroquinolone prescribing appears to explain the decline in incidence of C difficile infections, above other measures, in Oxfordshire and Leeds, England. Antimicrobial stewardship should be a central component of C difficile infection control programmes.

fundingUK Clinical Research Collaboration (Medical Research Council, Wellcome Trust, National Institute for Health Research); NIHR Oxford Biomedical Research Centre; NIHR Health Protection Research Unit on Healthcare Associated Infection and Antimicrobial Resistance (Oxford University in partnership with Public Health England [PHE]), and on Modelling Methodology (Imperial College, London in partnership with PHE); and the Health Innovation Challenge Fund.

Indexed as

Anti-Bacterial AgentsClostridioides difficileClostridium InfectionsCross InfectionEnglandFluoroquinolonesGenome-Wide Association StudyHumansIncidenceInfection ControlMultilocus Sequence TypingAnti-Bacterial AgentsFluoroquinolones

Identifiers

PMID28130063
PMCPMC5368411

What OpenQuestion holds

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LicenceCC BY
Read underepoch 390

Registered trials

None linked

Read under generation 80e0d062 · epoch 390. Bibliography from PubMed, PubMed Central and OpenAlex; grants from NIH RePORTER; trial links from ClinicalTrials.gov; estimates, votes and beliefs from the OpenQuestion graph.