A case-control study of community-associated Clostridium difficile infection

J Antimicrob Chemother. 2008 Aug;62(2):388-96. doi: 10.1093/jac/dkn163. Epub 2008 Apr 22.


Objectives: The aim of this study was to determine the incidence of and risk factors for community-associated Clostridium difficile infection (CDI).

Methods: Prospective surveillance of community-derived faecal samples for C. difficile cytotoxin, followed by a questionnaire-based case-control study in two distinct patient cohorts (one semi-rural and the other urban).

Results: The proportion of randomly selected faecal samples positive for C. difficile cytotoxin was 2.1% in both patient cohorts (median ages 73 and 45 years for the urban and semi-rural cohorts, respectively). Exposure to antibiotics in the previous 4 weeks, particularly multiple agents (P < 0.001), aminopenicillins (P < 0.05) and oral cephalosporins (P < 0.05), was significantly more frequent among cases than controls. Hospitalization in the preceding 6 months was significantly associated with CDI (45% versus 23%; P = 0.022). However, almost half the cases had not received antibiotic therapy in the month before C. difficile detection, and approximately one-third neither had exposure to antibiotics nor recent hospitalization. Contact with infants aged < or =2 years was significantly associated with CDI (14% versus 2%; P = 0.02). Prior exposure to gastrointestinal-acting drugs (proton pump inhibitor, H2 antagonist or non-steroidal anti-inflammatory) was not significantly more common in CDI cases. C. difficile PCR ribotype 001 caused 60% and 13% of urban and semi-rural community-associated CDI cases, respectively.

Conclusions: Reliance on antibiotic history and age (> or =65 years) will contribute to missed diagnoses of community-associated CDI. Potential risk factors for community-associated CDI should be explored further to explain the large proportion of cases not linked to recent antibiotic therapy or hospitalization.

Publication types

  • Research Support, Non-U.S. Gov't

MeSH terms

  • Adolescent
  • Adult
  • Aged
  • Aged, 80 and over
  • Anti-Bacterial Agents / therapeutic use
  • Bacterial Typing Techniques
  • Case-Control Studies
  • Child
  • Child, Preschool
  • Clostridioides difficile / classification
  • Clostridioides difficile / genetics
  • Clostridioides difficile / isolation & purification*
  • Community-Acquired Infections / epidemiology*
  • Community-Acquired Infections / microbiology*
  • DNA Fingerprinting
  • DNA, Bacterial / genetics
  • Enterocolitis, Pseudomembranous / epidemiology*
  • Enterocolitis, Pseudomembranous / microbiology*
  • Feces / microbiology
  • Female
  • Genotype
  • Hospitalization
  • Humans
  • Incidence
  • Male
  • Middle Aged
  • Polymerase Chain Reaction / methods
  • Prospective Studies
  • Risk Factors
  • Rural Population
  • Surveys and Questionnaires
  • Time Factors
  • Urban Population


  • Anti-Bacterial Agents
  • DNA, Bacterial