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Lower Risk of Recurrent Clostridioides difficile Infections Shown Over Past Decade


A 16% lower adjusted risk in recurrent Clostridioides difficile infections was found in 2018 compared with 2013 across diverse US sites part of the CDC’s Emerging Infections Program.

Risk of recurrent Clostridioides difficile infections (CDIs) was found to decrease from 2013 to 2018 across 10 US sites, according to study findings published in Open Forum Infectious Diseases.

Occurring in more than 1 in 5 patients with initial CDI, recurrent CDI is associated with substantial morbidity and mortality. The public health impact of CDI is also substantial, with as much as $4.8 billion attributed to acute care facilities due to extended length of stay and associated costs.

“Since 2013, several factors might have impacted [recurrent] CDI rates, including the following: the increased diagnostic use of nucleic acid amplification tests (NAATs), which are highly sensitive but less specific for toxin-producing disease; changes in CDI treatment; and decreasing prevalence of ribotype 027, a strain associated with a higher risk of recurrence,” said the study authors.

Seeking to explore whether these changes affected recurrent CDI rates, researchers conducted a multisite study of patients with initial CDI in 2018 and 2013 who were treated at diverse US sites part of the CDC’s Emerging Infections Program (EIP).

“EIP conducts population-based CDI surveillance in 10 sites: California, Colorado, Connecticut, Georgia, Maryland, Minnesota, New Mexico, New York, Oregon, and Tennessee.”

A total of 26,003 patients with initial CDI in 2018 (n = 12,283) and 2013 (n = 13,720) were compared on 180-day recurrent CDI rates, defined as a positive test greater than or equal to 14 days from the previous positive test.

Among the cohort, fewer patients in 2018 compared with 2013 were greater than or equal to 65 years old (45.5% vs 51.2%; P < .0001) and had hospital-onset (19.5% vs 24.7%) or long-term care facility (LTCF)–onset (10.3% vs 18.3%) CDI (P < .0001).

Moreover, a greater proportion of patients in 2018 than in 2013 had their initial CDI diagnosed by a laboratory that used NAAT (90.9% vs 78.7%; P < .0001) and were treated with vancomycin (66.5% vs 32.0%; P < .0001) or fidaxomicin (1.3% vs 0.9%; P = .04).

Within 180 days of initial CDI, 2250 (18.3%) patients in 2018 had 1 or more recurrence, compared with 2889 (21.1%) patients in 2013 (P < .0001). A significant difference in the overall adjusted risk of 180-day recurrent CDI was also shown in 2018, with these patients exhibiting a 16% lower risk than those treated in 2013 (P < .0001).

No difference in the adjusted risk of recurrent CDI was observed between 2018 and 2013 in the sensitivity analysis stratifying for toxin-positive cases (P = .79). Isolates from the initial CDI were available for 833 (6.8%) patients in 2018 and 1004 (7.3%) patients in 2013, and ribotype 027 was less frequently detected in 2018 compared with 2013 (8.3% vs 16.1%; P < .0001).

As laboratory diagnosis was used to define CDI, researchers noted that some patients may have been colonized or had a positive result for a test of cure rather than a true recurrence, particularly in 2013. Additional limitations included the lack of systematic measurement for positive tests of patients tested outside the catchment area, which might have led to an underestimation of recurrent CDI, as well as missing values for race in the medical records of one-fifth of the patients from Colorado and Georgia.

“As the epidemiology of CDI continues to evolve and novel therapies are introduced, continued monitoring of [recurrent] CDI is needed to guide prevention and treatment efforts,” concluded researchers.


Guh AY, Yi SH, Baggs J, et al. Comparison of the risk of recurrent Clostridioides difficile infections among patients in 2018 versus 2013. Open Forum Infect Dis. 2022;9(9):ofac422. doi:10.1093/ofid/ofac422

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