Unintended Consequence of Antimicrobial Stewardship: Use of Piperacillin and Tazobactam in Preference to Gentamicin for Urine Infection Was Associated With Clostridium difficile Infection in a High-Risk Spinal Cord Injury Patient, a Case Report

Abstract

A 60-year-old man with paraplegia due to epidural abscess received ceftriaxone, flucloxacillin, clindamycin, doxycycline, metronidazole, teicoplanin, meropenem, gentamicin, and tazobactam/piperacillin prior to transfer to spinal injuries unit for rehabilitation. During his stay in spinal unit, he developed urinary tract infection due to Escherichia coli, which was sensitive to gentamicin, and piperacillin/tazobactam. In the spinal unit, an outbreak of gentamicin-resistant Klebsiella pneumoniae occurred in 2019; to control this outbreak, amongst other measures, the prescribing habit was changed. Use of gentamicin was restricted; instead, piperacillin and tazobactam were prescribed for treatment of urinary tract infection. Six days after completing the course of piperacillin and tazobactam, this patient passed loose stools. Stool revealed toxin-producing Clostridium difficile (C. difficile), which was treated successfully with fidaxomicin, 200 mg every 12 h for 12 days. This patient had several risk factors for C. difficile infection. Penicillin combination antibiotics, such as co-amoxiclav and piperacillin and tazobactam, are associated with an increased risk of C. difficile infection. In contrast, gentamicin has low propensity to cause C. difficile infection, as gentamicin does not enter the colonic lumen when it is given intravenously. Perhaps, treatment of urinary tract infection with gut-sparing antibiotic might have reduced the risk of C. difficile infection in this patient, who was already at risk for developing C. difficile infection.

Clin Infect Immun. 2022;7(1):22-26
doi: https://doi.org/10.14740/cii145