Host and pathogen factors for Clostridium difficile infection and colonization

N Engl J Med. 2011 Nov 3;365(18):1693-703. doi: 10.1056/NEJMoa1012413.


Background: Clostridium difficile infection is the leading cause of health care-associated diarrhea, and the bacterium can also be carried asymptomatically. The objective of this study was to identify host and bacterial factors associated with health care-associated acquisition of C. difficile infection and colonization.

Methods: We conducted a 15-month prospective study in six Canadian hospitals in Quebec and Ontario. Demographic information, known risk factors, potential confounding factors, and weekly stool samples or rectal swabs were collected. Pulsed-field gel electrophoresis (PFGE) was performed on C. difficile isolates to determine the genotype. Levels of serum antibodies against C. difficile toxins A and B were measured.

Results: A total of 4143 patients were included in the study; 117 (2.8%) and 123 (3.0%) had health care-associated C. difficile infection and colonization, respectively. Older age and use of antibiotics and proton-pump inhibitors were significantly associated with health care-associated C. difficile infection. Hospitalization in the previous 2 months; use of chemotherapy, proton-pump inhibitors, and H(2) blockers; and antibodies against toxin B were associated with health care-associated C. difficile colonization. Among patients with health care-associated C. difficile infection and those with colonization, 62.7% and 36.1%, respectively, had the North American PFGE type 1 (NAP1) strain.

Conclusions: In this study, health care-associated C. difficile infection and colonization were differentially associated with defined host and pathogen variables. The NAP1 strain was predominant among patients with C. difficile infection, whereas asymptomatic patients were more likely to be colonized with other strains. (Funded by the Consortium de Recherche sur le Clostridium difficile.).

Publication types

  • Research Support, Non-U.S. Gov't

MeSH terms

  • Age Factors
  • Aged
  • Anti-Bacterial Agents / adverse effects*
  • Clostridioides difficile* / classification
  • Clostridioides difficile* / genetics
  • Clostridioides difficile* / isolation & purification
  • Clostridium Infections / chemically induced
  • Clostridium Infections / microbiology*
  • Colony Count, Microbial
  • Cross Infection / microbiology*
  • Diarrhea / microbiology
  • Feces / microbiology
  • Female
  • Humans
  • Length of Stay
  • Logistic Models
  • Male
  • Middle Aged
  • Proton Pump Inhibitors / adverse effects*
  • Risk Factors
  • Virulence Factors / genetics


  • Anti-Bacterial Agents
  • Proton Pump Inhibitors
  • Virulence Factors