Introduction: Antibiotic-associated Clostridium difficile diarrhoea may complicate surgery for proximal femoral fracture. We sought to determine whether a change in antibiotic policy in our unit influenced rates of infection with C. difficile following hip fracture surgery.

Methods: A 4 year case controlled study. A change in antibiotic prophylaxis was introduced during a 3 month period in 2005. Infection rates with C. difficile were compared for 2 years either side of this period. The initial regimen was one of three doses of cefuroxime (1.5 g). The new regimen is a single dose of cefuroxime (1.5 g) with gentamicin (240 mg) at induction. Infection was defined as diarrhoea with a positive isolate within 30 days of surgery.

Results: Prior to the change in prophylaxis, 912 patients underwent surgery for neck of femur fracture. Following the change, 899 patients underwent surgery over the period March 2005 to March 2007. 38 patients developed C. difficile infection (4.2%) in the initial group, compared with 14 patients (1.6%) in the group following the change in prophylaxis (P=0.009). Patients with C difficile infection also had a statistically significant increase in antibiotic exposure, inpatient stay, morbidity and inpatient mortality.

Discussion: The main challenges regarding antibiotic selection are failure of prophylaxis, often because of infection with MRSA, and C. difficile-associated diarrhoea as a consequence of antibiotic prophylaxis. Infection with C. difficile is reduced with the new regimen. We advocate the use of the new regimen as an effective alternative to multiple dose cephalosporins for the prevention of C. difficile infection in this group of high risk patients.