Epidemiologic Data Show High CDI Prevalence in China, Significant Regional Differences

Epidemiologic data indicate a high prevalence of CDI in China and significant regional differences in circulating CDI strains, suggesting the need for better infection control and surveillance.

Results of a systematic review and meta-analysis show a high prevalence of Clostridiodes difficile infection (CDI) in China, with significant regional differences in the predominant circulating CDI strains. These findings were published in the International Journal of Infectious Diseases.

Researchers conducted this analysis using data captured from 50 studies that were conducted between January 2017 and February 2022. The analysis was restricted to case-control, cohort, and cross-sectional studies, and study patients were those with CDI confirmed via toxigenic culture analysis, cytotoxicity neutralization assay, or 2-step algorithms. The primary outcome was CDI prevalence; secondary outcomes were the molecular characteristics of CDI. Random-effects and common-effects models were used for the meta-analysis and selected on the basis of study heterogeneity. Genotype characteristics were identified using multilocus sequence typing and polymerase chain reaction-ribotyping methods.

A total of 50 studies were included in the final analysis, of which 33 examined CDI prevalence. 

[A]wareness and diagnosis of CDI should be further improved, and more accurate epidemiological data should be obtained to better prevent CDI.

Data captured from 26,852 patients showed 2696 were diagnosed with CDI within the 5-year study period, indicating a pooled CDI prevalence of 11.4% (95% CI, 9.1%-13.9%; I2, 93.9%, P <.001). Although CDI prevalence was found to be higher in Southern (11.0%; 95% CI, 8.4%-13.8%) vs Northern (13.6%; 95% CI, 9.4%-18.5%) China, the difference was not statistically significant. 

In regard to molecular characteristics, the researchers identified ST54, ST3, and ST37 as the most prevalent CDI strains. The overall prevalence of ST54 was 14.0% (95% CI, 12.1%-15.9%); ST3 was 12.9% (95% CI, 11.2%-14.6%); and ST37 was 10.1% (95% CI, 8.0%-12.4%). However, the predominant circulating CDI strains varied by region, with ST54 (16%; 95% CI, 13.6%-18.5%), ST3 (13.6%; 95% CI, 11.7%-15.8%), and ST37 (11.6%; 95% CI, 8.6%-14.9%) as the most prevalent CDI strains in Southern China vs ST2 (13.9%; 95% CI, 11.8%-16.1%), ST3 (11.0%; 95% CI, 8.1%-14.4%), and ST54 (10.1%; 95% CI, 8.5%-11.9%) in Northern China.

Data from 8 studies indicated a pooled prevalence of 13.6% (95% CI, 8.1%-20.2%) for C difficile colonization.

Limitations of this study include significant heterogeneity, as well as a lack of epidemiologic data on CDI for certain provinces in China. 

According to the researchers, “[A]wareness and diagnosis of CDI should be further improved, and more accurate epidemiological data should be obtained to better prevent CDI.” 


Wen BJ, Dong N, Ouyang ZR, et al. Prevalence and molecular characterization of Clostridioides difficile infection in China over the past five years: a systematic review and meta-analysis. Int J Infect Dis. Published online March 9, 2023. doi:10.1016/j.ijid.2023.03.009.