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Prescriber perceptions of fluoroquinolones, extended-spectrum cephalosporins, and Clostridioides difficile infection

Published online by Cambridge University Press:  29 May 2020

Julia E. Szymczak*
Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania Division of Infectious Diseases, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
Brandi M. Muller
Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
Nikitha Shankar Shakamuri
Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
Keith W. Hamilton
Division of Infectious Diseases, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
Jeffrey S. Gerber
Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania Division of Infectious Diseases, Department of Pediatrics, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
Maryrose Laguio-Vila
Department of Infectious Diseases, Rochester General Hospital, Rochester, New York
Ghinwa K. Dumyati
Center for Community Health and Prevention, University of Rochester Medical Center, Rochester, New York New York Emerging Infections Program, Rochester, New York
Scott K. Fridkin
Department of Medicine, School of Medicine, Emory University, Atlanta, Georgia Georgia Emerging Infections Program, Atlanta Veterans’ Affairs Medical Center, Decatur, Georgia
Alice Y. Guh
Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, AtlantaGeorgia
Sujan C. Reddy
Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, AtlantaGeorgia
Ebbing Lautenbach
Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania Division of Infectious Diseases, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
Author for correspondence: Julia E. Szymczak, E-mail:



Fluoroquinolones (FQs) and extended-spectrum cephalosporins (ESCs) are associated with higher risk of Clostridioides difficile infection (CDI). Decreasing the unnecessary use of FQs and ESCs is a goal of antimicrobial stewardship. Understanding how prescribers perceive the risks and benefits of FQs and ESCs is needed.


We conducted interviews with clinicians from 4 hospitals. Interviews elicited respondent perceptions about the risk of ESCs, FQs, and CDI. Interviews were audio recorded, transcribed, and analyzed using a flexible coding approach.


Interviews were conducted with 64 respondents (38 physicians, 7 nurses, 6 advance practice providers, and 13 pharmacists). ESCs and FQs were perceived to have many benefits, including infrequent dosing, breadth of coverage, and greater patient adherence after hospital discharge. Prescribers stated that it was easy to make decisions about these drugs, so they were especially appealing to use in the context of time pressures. They described having difficulty discontinuing these drugs when prescribed by others due to inertia and fear. Prescribers were skeptical about targeting specific drugs as a stewardship approach and felt that the risk of a negative outcome from under treatment of a suspected bacterial infection was a higher priority than the prevention of CDI.


Prescribers in this study perceived many advantages to using ESCs and FQs, especially under conditions of time pressure and uncertainty. In making decisions about these drugs, prescribers balance risk and benefit, and they believed that the risk of CDI was acceptable in compared with the risk of undertreatment.

Original Article
© 2020 by The Society for Healthcare Epidemiology of America. All rights reserved.

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PREVIOUS PRESENTATION: The findings of this study were presented as an oral abstract (no. 474) at the 2019 Society for Healthcare Epidemiology (SHEA) Spring Conference on April 25, 2019, in Boston, Massachusetts.


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