Assessing the Ability of Hospital Diagnosis Codes to Detect Inpatient Exposure to Antibacterial Agents

OBJECTIVE Because antibacterial history is difficult to obtain, especially when the exposure occurred at an outside hospital, we assessed whether infection-related diagnostic billing codes, which are more readily available through hospital discharge databases, could infer prior antibacterial receipt. DESIGN Retrospective cohort study. PARTICIPANTS This study included 121,916 hospitalizations representing 78,094 patients across the 3 hospitals. METHODS We obtained hospital inpatient data from 3 Chicago-area hospitals. Encounters were categorized as "infection" if at least 1 International Classification of Disease, Ninth Revision, Clinical Modification (ICD-9-CM) code indicated a bacterial infection. From medication administration records, we categorized antibacterial agents and calculated total therapy days using Centers for Disease Control and Prevention (CDC) definitions. We evaluated bivariate associations between infection encounters and 3 categories of antibacterial exposure: any, broad spectrum, or surgical prophylaxis. We constructed multivariable models to evaluate adjusted risk ratios for antibacterial receipt. RESULTS Of the 121,916 inpatient encounters (78,094 patients) across the 3 hospitals, 24% had an associated infection code, 47% received an antibacterial, and 13% received a broad-spectrum antibacterial. Infection-related ICD-9-CM codes were associated with a 2-fold increase in antibacterial administration compared to those lacking such codes (RR, 2.29; 95% confidence interval [CI], 2.27-2.31) and a 5-fold increased risk for broad-spectrum antibacterial administration (RR, 5.52; 95% CI, 5.37-5.67). Encounters with infection codes had 3 times the number of antibacterial days. CONCLUSIONS Infection diagnostic billing codes are strong surrogate markers for prior antibacterial exposure, especially to broad-spectrum antibacterial agents; such an association can be used to enhance early identification of patients at risk of multidrug-resistant organism (MDRO) carriage at the time of admission. Infect Control Hosp Epidemiol 2018;39:377-382.

[Pneumonia associated with mechanical ventilation. Update and recommendations inter- Societies SADI-SATI]

Representatives of the Argentine Society of Infectious Diseases (SADI) and the Argentine Society of Intensive Therapy (SATI) worked together on the development of specific recommendations for the diagnosis, treatment and prevention of ventilator-associated pneumonia (VAP). The methodology used was the analysis of the literature published in the last 15 years, complemented with the opinion of experts and local data. This document aims to offer basic tools to optimize diagnosis based on clinical and microbiological criteria, orientation in empirical and targeted antibiotic schemes, news on posology and administration of antibiotics in critical patients and to promote effective measures to reduce the risk of VAP. It also offers a diagnostic and treatment algorithm and considerations on inhaled antibiotics. The joint work of both societies -infectious diseases and intensive care- highlights the concern for the management of VAP and the importance of ensuring improvement in daily practices. This guideline established recommendations to optimize the diagnosis, treatment and prevention of VAP in order to reduce morbidity and mortality, days of hospitalization, costs and resistance to antibiotics due to misuse of antimicrobials.

Primary and Secondary Antibiotic Resistance of Helicobacter pylori in Israeli Children and Adolescents

BACKGROUND

Empiric treatment for Helicobacter pylori is influenced by antibiotic susceptibility of infecting strains. A rise in the resistance rate to clarithromycin and metronidazole has been reported in pediatric populations.

OBJECTIVES

To assess the primary and secondary antibiotic resistance of H. pylori isolates in Israeli children and adolescents.

METHODS

A retrospective review of H. pylori isolates cultured from antral biopsies of consecutive children aged 1 to 18 years, who were referred to the Pediatric Gastroenterology Unit, Kaplan Medical Center, over a 2.8 year period, was performed. Antibiotic susceptibility to clarithromycin, metronidazole, amoxicillin, tetracycline, and levofloxacin was determined by E-test. Data on the age of the patient, indication for endoscopy, and antibiotic treatment for H. pylori in previously treated children was collected.

RESULTS

Cultures for H. pylori yielded 123 isolates. In children not previously treated (n=95), the primary global resistance was 38% with resistance to clarithromycin 9.5%, metronidazole 32.6 %, and to both 4.2%. Respective rates of resistance in previously treated children (n=28) were 71% (P = 0.002), 29% (P = 0.02), and 61% (P = 0.007). Simultaneous resistance to both drugs was found in 18% (P = 0.02). All H. pylori strains were susceptible to amoxicillin, tetracycline, and levofloxacin. Past eradication treatment was the only independent risk factor for antibiotic resistance in multivariate analysis.

CONCLUSIONS

Significantly higher resistance rates were found in previously treated patients, stressing the need to refrain from empiric treatment using the "test and treat strategy." Culture-based treatment strategy should be considered in all previously treated children.

Antibiotic drug usage in pigs in Germany-Are the class profiles changing?

The development of antimicrobial resistance is triggered by the use of antibiotic drugs. Therefore, the consumption of antibiotics in livestock is monitored, and different measures may be applied if the usage of antibiotic drugs seems inappropriate. Unfortunately, the surveillance of antibiotic consumption is not standardised, and surveillance systems differ. In Germany, the food quality assurance system QS Qualität und Sicherheit GmbH (QS) began the documentation of antibiotic drug usage in pigs in 2012 in a private economic based database, and for its members, documentation has been mandatory in all pig age groups since 2014. In this investigation, we calculated the distribution of the antibiotics use per pig age group and half-year, and the percentage of the active substances used from overall treatments within German pig holdings from 1 July, 2013 to 30 June, 2015. In fattening pigs, the median of the treatment frequency is 4.3 in 2013-2 and exhibits a decreasing trend in this time period up to 2.1 in 2015-1. In weaners the median ranged between 11.3 in 2014-2 and 5.8 in 2013-2. The median of sucklers varies between 21.6 and 25.0. In sucklers and weaners, a clear temporal trend is not seen to date. The share of the active substances differs between the age groups. In fattening pigs, mostly tetracyclines and penicillines were used, occurring in approximately 60% of the total treatments. In weaners, amoxicillin and colistin have the highest shares of the treatment frequency, at approximately 60%. The treatment frequencies of macrolides and penicillines have the highest share in sucklers.

Community-associated methicillin-resistant Staphylococcus aureus infection: Literature review and clinical update

OBJECTIVE

To provide information on the prevalence and treatment of methicillin-resistant Staphylococcus aureus (MRSA) infections and the distinction between community-associated MRSA and health care-associated MRSA.

QUALITY OF EVIDENCE

The MEDLINE and EMBASE databases were searched from 2005 to 2016. Epidemiologic studies were summarized and the relevant treatment literature was based on level I evidence.

MAIN MESSAGE

The incidence of community-associated MRSA infection is rising. Certain populations, including indigenous Canadians and homeless populations, are particularly affected. Community-associated MRSA can be distinguished from health care-associated MRSA based on genetic, epidemiologic, or microbiological profiles. It retains susceptibility to some oral agents including trimethoprim-sulfamethoxazole, clindamycin, and tetracyclines. Community-associated MRSA typically presents as purulent skin and soft tissue infection, but invasive infection occurs and can lead to severe, complicated disease. Treatment choices and the need for empiric MRSA coverage are influenced by the type and severity of infection.

CONCLUSION

Community-associated MRSA is a common cause of skin and soft tissue infections and might be common in populations where overcrowding and limited access to clean water exist.

Bacterial clonal diagnostics as a tool for evidence-based empiric antibiotic selection

Despite the known clonal distribution of antibiotic resistance in many bacteria, empiric (pre-culture) antibiotic selection still relies heavily on species-level cumulative antibiograms, resulting in overuse of broad-spectrum agents and excessive antibiotic/pathogen mismatch. Urinary tract infections (UTIs), which account for a large share of antibiotic use, are caused predominantly by Escherichia coli, a highly clonal pathogen. In an observational clinical cohort study of urgent care patients with suspected UTI, we assessed the potential for E. coli clonal-level antibiograms to improve empiric antibiotic selection. A novel PCR-based clonotyping assay was applied to fresh urine samples to rapidly detect E. coli and the urine strain's clonotype. Based on a database of clonotype-specific antibiograms, the acceptability of various antibiotics for empiric therapy was inferred using a 20%, 10%, and 30% allowed resistance threshold. The test's performance characteristics and possible effects on prescribing were assessed. The rapid test identified E. coli clonotypes directly in patients' urine within 25-35 minutes, with high specificity and sensitivity compared to culture. Antibiotic selection based on a clonotype-specific antibiogram could reduce the relative likelihood of antibiotic/pathogen mismatch by ≥ 60%. Compared to observed prescribing patterns, clonal diagnostics-guided antibiotic selection could safely double the use of trimethoprim/sulfamethoxazole and minimize fluoroquinolone use. In summary, a rapid clonotyping test showed promise for improving empiric antibiotic prescribing for E. coli UTI, including reversing preferential use of fluoroquinolones over trimethoprim/sulfamethoxazole. The clonal diagnostics approach merges epidemiologic surveillance, antimicrobial stewardship, and molecular diagnostics to bring evidence-based medicine directly to the point of care.

Effectiveness of a stepwise Pseudomonas aeruginosa eradication protocol in children with cystic fibrosis

INTRODUCTION

Antibiotic eradication therapy (AET) for initial Pseudomonas aeruginosa (Pa) infection is standard of care in children with cystic fibrosis (CF), but information is limited on treatment for patients who fail initial AET. The aim of this study was to evaluate the effectiveness of a multi-step protocol for AET for new-onset Pa infections in children with CF.

METHODS

A three-step AET protocol which includes: (step 1) 28days of tobramycin inhalation solution (TIS) for new-onset Pa infection; (step 2) a second course of TIS for patients with positive respiratory tract culture after step 1; (step 3) 14days of intravenous antibiotics followed by 28days of TIS for patients with a subsequent positive culture. We conducted a retrospective review of all pediatric CF patients who underwent the eradication protocol between January 2010 and December 2015. The success rate of each step and of the overall protocol was recorded.

RESULTS

During the study period, 128 patients had a total of 213 new-onset Pa infections. Of 195 asymptomatic episodes, 150 (76.9%, 95% CI 70.4; 82.6) cleared after step 1 and 12 cleared after step 2 (33.3% (95% CI 18.6; 50.9) stepwise success rate and 87.1% (95% CI 77.1; 88.1) cumulative success rate). Intravenous antibiotics followed by 28days of TIS were administered in 24 episodes; this was successful in 10 episodes (41.7%; 95% CI 22.1; 63.4). The regimen in asymptomatic patients failed in fourteen episodes (7.5%; 95% CI 4.2; 12.3) then considered chronically infected with Pa. Overall, the cumulative success rate of the asymptomatic arm was 88.2% (95% CI 82.8; 92.4).

CONCLUSION

The first step of the AET protocol led to the greatest eradication success. Subsequent eradication attempts have a success rate below 50%. Prospective studies of eradication protocols for this population are needed to determine the most effective treatment strategy.

Functional Metagenomics as a Tool for Identification of New Antibiotic Resistance Genes from Natural Environments

Antibiotic resistance has become a major concern for human and animal health, as therapeutic alternatives to treat multidrug-resistant microorganisms are rapidly dwindling. The problem is compounded by low investment in antibiotic research and lack of new effective antimicrobial drugs on the market. Exploring environmental antibiotic resistance genes (ARGs) will help us to better understand bacterial resistance mechanisms, which may be the key to identifying new drug targets. Because most environment-associated microorganisms are not yet cultivable, culture-independent techniques are essential to determine which organisms are present in a given environmental sample and allow the assessment and utilization of the genetic wealth they represent. Metagenomics represents a powerful tool to achieve these goals using sequence-based and functional-based approaches. Functional metagenomic approaches are particularly well suited to the identification new ARGs from natural environments because, unlike sequence-based approaches, they do not require previous knowledge of these genes. This review discusses functional metagenomics-based ARG research and describes new possibilities for surveying the resistome in environmental samples.

Effect of freezing sputum on Pseudomonas aeruginosa population heterogeneity

Pseudomonas aeruginosa develops profound population heterogeneity in CF airways. How changes in these populations relate to clinical status is unknown. In order to facilitate this understanding, frequent sampling of this community is required. To determine if the collection and storage of sputum at home may pose a viable option, we collected sputum from ten patients. Sputum samples were partitioned in two, with half immediately processed on MacConkey agar and half assessed after freezing for one week in a home-freezer. From each sample, 88 isolates were assessed for antibiotic susceptibility and virulence factor production. Freezing resulted in a 10³CFU/ml drop in P. aeruginosa. However, across 1760 isolates, no consistent difference in either antibiotic susceptibility nor virulence factors was observed suggesting freezing induced indiscriminate killing. Home collection and freezing of sputum will enable frequent and convenient assessment of P. aeruginosa population dynamics in CF.

[One year of infectious diseases : a review]

Several outbreaks have made the news in 2016 : Ebola has come at an end, Zika is booming and a resurgence of yellow fever takes place in Africa. In Switzerland, two hospital outbreaks have been reported, caused by Mycobacterium chimerae and Burkholderia cepacia. A major new article has consolidated the notion that prolonged antibiotic therapy is unnecessary in Lyme disease. As multiresistant bacteria are increasing in frequency, innovative therapeutic approaches are under development. For lung infections, sensitive and specific methods are in need to refine their etiological diagnosis. In pneumonia, therapy can be shortened without risk compared with usual practice. Finally, the epidemiology of bacterial meningitis has changed in the last 10 years, with a decrease of incidence.

Estimated antimicrobial dispensing frequency and preferences for lactating cow therapy by Ontario dairy veterinarians

In this cross-sectional study, data were collected from responses to a questionnaire on dispensing frequencies of antimicrobials used by dairy practitioners in Ontario in dairy cattle in 2001. Data were validated through clinical case scenarios. Respondents reported using antimicrobials across all categories of importance to human medicine (medically important, Categories I to III) with a diversity of treatment combinations and routes of administration. Respondents anticipated that a request for direct veterinary supervision by producers was dependent on case severity, highlighting the importance of on-farm diagnostic and treatment protocols. Knowledge of the antimicrobials used in lactating cow therapy, and their frequency and reasons for use, will provide baseline information and contribute to antimicrobial stewardship in this food-animal production sector.

Return to sender: the need to re-address patient antibiotic allergy labels in Australia and New Zealand

BACKGROUND/AIM

Antibiotic allergies are frequently reported and have significant impacts upon appropriate prescribing and clinical outcomes. We surveyed infectious diseases physicians, allergists, clinical immunologists and hospital pharmacists to evaluate antibiotic allergy knowledge and service delivery in Australia and New Zealand.

METHODS

An online multi-choice questionnaire was developed and endorsed by representatives of the Australasian Society of Clinical Immunology and Allergy (ASCIA) and the Australasian Society of Infectious Diseases (ASID). The 37-item survey was distributed in April 2015 to members of ASCIA, ASID, the Society of Hospital Pharmacists of Australia and the Royal Australasian College of Physicians.

RESULTS

Of 277 respondents, 94% currently use or would utilise antibiotic allergy testing (AAT) and reported seeing up to 10 patients/week labelled as antibiotic-allergic. Forty-two per cent were not aware of or did not have AAT available. Most felt that AAT would aid antibiotic selection, antibiotic appropriateness and antimicrobial stewardship (79, 69 and 61% respectively). Patients with the histories of immediate hypersensitivity were more likely to be referred than those with delayed hypersensitivities (76 vs 41%, P = 0.0001). Lack of specialist physicians (20%) and personal experience (17%) were barriers to service delivery. A multidisciplinary approach was a preferred AAT model (53%). Knowledge gaps were identified, with the majority overestimating rates of penicillin/cephalosporin (78%), penicillin/carbapenem (57%) and penicillin/monobactam (39%) cross-reactivity.

CONCLUSIONS

A high burden of antibiotic allergy labelling and demand for AAT is complicated by a relative lack availability or awareness of AAT services in Australia and New Zealand. Antibiotic allergy education and deployment of AAT, accessible to community and hospital-based clinicians, may improve clinical decisions and reduce antibiotic allergy impacts. A collaborative approach involving infectious diseases physicians, pharmacists and allergists/immunologists is required.

Antimicrobial Resistance Profile of Planktonic and Biofilm Cells of Staphylococcus aureus and Coagulase-Negative Staphylococci

The objective of the present study was to determine the antimicrobial resistance profile of planktonic and biofilm cells of Staphylococcus aureus and coagulase-negative staphylococci (CoNS). Two hundred Staphylococcus spp. strains were studied, including 50 S. aureus and 150 CoNS strains (50 S. epidermidis, 20 S. haemolyticus, 20 S. warneri, 20 S. hominis, 20 S. lugdunensis, and 20 S. saprophyticus). Biofilm formation was investigated by adherence to polystyrene plates. Positive strains were submitted to the broth microdilution method to determine the minimum inhibitory concentration (MIC) for planktonic and biofilm cells and the minimal bactericidal concentration for biofilm cells (MBCB). Forty-nine Staphylococcus spp. strains (14 S. aureus, 13 S. epidermidis, 13 S. saprophyticus, 3 S. haemolyticus, 1 S. hominis, 3 S. warneri, and 2 S. lugdunensis) were biofilm producers. These isolates were evaluated regarding their resistance profile. Determination of planktonic cell MIC identified three (21.4%) S. aureus strains that were resistant to oxacillin and six (42.8%) that were resistant to erythromycin. Among the CoNS, 31 (88.6%) strains were resistant to oxacillin, 14 (40%) to erythromycin, 18 (51.4%) to gentamicin, and 8 (22.8%) to sulfamethoxazole/trimethoprim. None of the planktonic isolates were resistant to vancomycin or linezolid. MICs were 2-, 4-, 8-, and up to 16-fold higher for biofilm cells than for planktonic cells. This observation was more common for vancomycin and erythromycin. The MBCB ranged from 8 to >256 µg/mL for oxacillin, 128 to >128 µg/mL for vancomycin, 256 to >256 µg/mL for erythromycin and gentamicin, >64 µg/mL for linezolid, and 32/608 to >32/608 µg/mL for sulfamethoxazole/trimethoprim. The results showed considerably higher MICs for S. aureus and CoNS biofilm cells compared to planktonic cells. Analysis of MBCM confirmed that even high concentrations of vancomycin were unable to eliminate the biofilms of S. aureus and CoNS species. Linezolid was the most effective drug in inhibiting staphylococci in the biofilm, without an increase in the MIC, when compared to planktonic cells. None of the isolates were resistant to this drug.

Fluoroquinolone-resistance mechanisms and phylogenetic background of clinical Escherichia coli strains isolated in south-east Poland

Fluorochinolones are a class of broad-spectrum antimicrobials in the treatment of several infections, including those caused by Escherichia coli. Due to the increasing resistance of bacteria to antimicrobials, an understanding of fluoroquinolone resistance is important for infection control. The aim of this study was to determine susceptibility of clinical E. coli strains to fluoroquinolones and characterize their mechanisms of quinolone resistance. Totally, 79 non-duplicate clinical E. coli isolates included in this study were mainly from skin lesion -36 (45.6%) isolates; 54 (68.4%) isolates were assigned to phylogenetic B2 group. Resistance to ciprofloxacin was found in 20 isolates. In the quinolone resistance-determining region (QRDR) region of gyrA and parC, 4 types of point mutations were detected. Mutations in parC gene were found in all strains with gyrA mutations. Predominance of double mutation in codon 83 and 87 of gyrA (90%) and in codon 80 of parC (90%) was found. Moreover, plasmid-mediated quinolone resistance (PMRQ) determinants (qnrA or qnrB and/or aac(6')-Ib-cr) were present in 5 (25%) out of 20 fluoroquinolone-resistant isolates. Resistance to fluoroquinolones in all of the tested clinical E. coli isolates correlated with point mutations in both gyrA and parC. The majority of fluoroquinolone-resistant strains belonged to D and B2 phylogenetic groups.

Identification of Optimal Combinations for Empirical Dual Antimicrobial Therapy of Pseudomonas aeruginosa Infection: Potential Role of a Combination Antibiogram

To better determine the optimal combinations for empirical dual antimicrobial therapy of Pseudomonas aeruginosa infection, we evaluated the utility of a novel combination antibiogram. Although the combination antibiogram allowed modest fine-tuning of choices for dual antibiotic therapy, selections based on the 2 antibiograms did not differ substantively. Drug combinations with the broadest coverage were consistently composed of an aminoglycoside and a β-lactam.

Evaluation of Drug Treatment of Bronchopneumonia at the Pediatric Clinic in Sarajevo

INTRODUCTION

Bronchopneumonia is the most common clinical manifestation of pneumonia in pediatric population and leading infectious cause of mortality in children under 5 years. Evaluation of treatment involves diagnostic procedures, assessment of disease severity and treatment for disease with an emphasis on vulnerability of the population.

AIM

To determine the most commonly used antibiotics at the Pediatric Clinic in Sarajevo and concomitant therapy in the treatment of bronchopneumonia.

PATIENTS AND METHODS

The study was retrospective and included a total of 104 patients, hospitalized in pulmonary department of the Pediatric Clinic in the period from July to December 2014. The treatment of bronchopneumonia at the Pediatric Clinic was empirical and it conformed to the guidelines and recommendations of British Thoracic Society.

RESULTS AND DISCUSSION

First and third generation of cephalosporins and penicillin antibiotics were the most widely used antimicrobials, with parenteral route of administration and average duration of treatment of 4.3 days. Concomitant therapy included antipyretics, corticosteroids, leukotriene antagonists, agonists of β2 adrenergic receptor. In addition to pharmacotherapy, hospitalized patients were subjected to a diet with controlled intake of sodium, which included probiotic-rich foods and adequate hydration. Recommendations for further antimicrobial treatment include oral administration of first-generation cephalosporins and penicillin antibiotics.

CONCLUSION

Results of the drug treatment of bronchopneumonia at the Pediatric Clinic of the University Clinical Center of Sarajevo are comparable to the guidelines of the British Thoracic Society. It is necessary to establish a system for rational use of antimicrobial agents in order to reduce bacterial resistance.

[CHARACTERISTICS OF ANTIBIOTICORESISTANCE OF MICROFLORA IN A COMBAT (THE GUN-SHOT ANO THE MINE-EXPLOSION) WOUNDS OF THE EXTREMITIES]

Abstract Results of bacteriological investigations of a gun-shot and a mine-explosion woundings of the extremities were analyzed in Military-Medical Clinical Centres (MMCC) of Kyiv, Lviv and Vinnytsya. Spectrum of the allotted microorganisms and profile of their antibioticoresistance were disclosed. The patterns of resistance were determined in accordance to offering of international experts of European Committee on Antimicrobial Susceptibility Testing (EUCAST). Dominating microflora in a Chief MMCC (Kyiv) and MMCC of a Western Region (Lviv) were various species of the Enterobacteriaceae and P. aeruginosa families, while in MMCC of a Central Region (Vinnytsya)--a gramm-negative non-fermentative bacilli of the Acinetobacter genus and Pseudomonas genus. The majority (79.5%) of isolates were characterized by polyresistance for antibiotics. Maximal quantity of strains with a widened spectrum of resistance was revealed in 2 - 3 weeks after a wounding--in 71.4 and 96.9% accordingly.

[ANALYSIS OF MICROFLORA OF PLEURAL CAVITY IN PLEURAL EMPYEMA]

In the pleural empyema (PE) treatment, not depending on introduction of multiple operative procedures and the medicinal preparations application, some issues remain unsolved, including the infection agents verification, the most rapid bronchial fistula elimination and the lung volume restoration. The EP infection agents spectrum, their sensitivity to preparations were revealed, as well as the enhanced rate of the methicillin-resistant stamms (MRSA) and the microorganisms associations verification. A reduction of the infection agents sensitivity towards "simple" antibacterial preparations was established, so the physicians, treating PE, must prescribe "hard" antibiotics, what enhances its cost.

[CHOOSING ANTIBIOTIC IN MICROBIOLOGICAL ANALYSIS OF INFECTIONS OF URINARY EXCRETION SYSTEM]

The effectiveness of application of test-system "Choice of antibiotic" was evaluated as a tool for incubation of maximal amount of bacteria from pathological material under acute cystitis. The results of meta-genome analysis established that test-system permits supporting growth of practically all bacteria detected in urine, including ones relating to "uncultivated for the present". The comparison of results of standard detection of sensitivity of bacteria to antibiotics and identification of effective pharmaceutical according the results of application of test-system "Choice of antibiotic" as well was implemented It is demonstrated that test- system permits choosing antibiotic during 6-20 hours wiihout isolation of pure strain.

[CHARACTERISTIC OF ANTIBIOTIC-ASSOCIATED DIARRHEA IN PATIENTS WITH ACUTE CEREBRAL CIRCULATION DISORDER]

This full-design study included patients admitted to the Regional Vascular Centre in 2013 and was aimed to obtain more detailed information on the need for medical aid, indications for antibacterial therapy and the spectrum of the drugs being prescribed 42 patients presented with antibiotic-associated diarrhea caused by Clostridium difficile. The composition of antibiotics used for mono- and combined therapy was analysed, details of the clinical picture are described, the importance of timely diagnostics and adequate treatment is emphasized.