As a result of a decline in healthcare–associated infections, the estimated burden of Clostridioides difficile infection in the United States decreased by an adjusted 24% from 2011 through 2017, according to study results published in the New England Journal of Medicine.

To assess the national progress in reducing C difficile infection, researchers used data from the Centers for Disease Control and Prevention Emerging Infections Program (EIP), which have been conducting population-based surveillance of C difficile infection in 10 US states since 2011, equaling more than 12 million persons in 2017.

Healthcare-associated infections were defined as an infection with onset during a stay in a healthcare facility or associated with recent admission to a healthcare facility; all others were classified as community-associated infections.

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Cases were adjusted for age, sex, race, and diagnostic method (nucleic acid amplification tests [NAATs] vs other test types). Although people diagnosed by NAAT increased from 55% in 2011 to 84% in 2016, and then decreased to 83% in 2017, researchers used the 2011 rate of 55% for each year to perform the trend analyses.

The number of reported EIP cases was 15,461 in 2011 (10,177 healthcare-associated and 5284 community-associated cases) and 15,512 in 2017 (7973 healthcare-associated and 7539 community-associated cases).

Without adjustment for NAAT use, the estimated total national burden C difficile infection was 476,400 cases (95% CI, 419,900-532,900; estimated incidence of 154.9 per 100,000 population) in 2011 and 462,100 cases (95% CI, 428,600-495,600; estimated incidence of 143.6 per 100,000 population) in 2017.

After adjustment of NAAT use to the 2011 rate of 55%, the estimated total burden of C difficile infection decreased by 24% (95% CI, 6%-36%) from 2011 to 2017; healthcare-associated infection decreased by 36% (95% CI, 24%-54%) but no change was seen in the burden of community-associated infection. Furthermore, the adjusted estimate of burden of hospitalizations decreased by 24% (95% CI, 0%-48%), but no significant changes were observed in the adjusted estimates of the burden of first recurrences and in-hospital deaths.

Researchers attributed the decrease in healthcare-associated infections to adherence to recommended infection-prevention practices. Specifically, they noted that a decline in ribotype 027 isolates, which may have been driven by reduced fluoroquinolone use in US hospitals and may have been a contributing factor to the decrease in healthcare-associated infections. They noted that understanding the role of nonhealthcare reservoirs in C difficile transmission needs to improve, because estimates of community-associated infection did not change after accounting for NAAT use.

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In addition, “the development of a C difficile vaccine and exploration of innovative strategies, such as gut microbiome restoration for primary prevention of C difficile infection, might also further reduce the burden of C difficile infection,” they concluded.

Disclosure: Several study authors declared affiliations with the pharmaceutical industry. Please see the original reference for a full list of authors’ disclosures.


Guh AY, Mu Y, Winston LG, et al; Emerging Infections Program Clostridioides difficile Infection Working Group. Trends in U.S. burden of Clostridioides difficile infection and outcomes. N Engl J Med. 2020;382(14):1320-1330.