Epidemiology of community-associated Clostridium difficile infection, 2009 through 2011

JAMA Intern Med. 2013 Jul 22;173(14):1359-67. doi: 10.1001/jamainternmed.2013.7056.


Importance: Clostridium difficile infection (CDI) has been increasingly reported among healthy individuals in the community. Recent data suggest that community-associated CDI represents one-third of all C difficile cases. The epidemiology and potential sources of C difficile in the community are not fully understood.

Objectives: To determine epidemiological and clinical characteristics of community-associated CDI and to explore potential sources of C difficile acquisition in the community.

Design and setting: Active population-based and laboratory-based CDI surveillance in 8 US states.

Participants: Medical records were reviewed and interviews performed to assess outpatient, household, and food exposures among patients with community-associated CDI (ie, toxin or molecular assay positive for C difficile and no overnight stay in a health care facility within 12 weeks). Molecular characterization of C difficile isolates was performed. Outpatient health care exposure in the prior 12 weeks among patients with community-associated CDI was a priori categorized into the following 3 levels: no exposure, low-level exposure (ie, outpatient visit with physician or dentist), or high-level exposure (ie, surgery, dialysis, emergency or urgent care visit, inpatient care with no overnight stay, or health care personnel with direct patient care).

Main outcomes and measures: Prevalence of outpatient health care exposure among patients with community-associated CDI and identification of potential sources of C difficile by level of outpatient health care exposure.

Results: Of 984 patients with community-associated CDI, 353 (35.9%) did not receive antibiotics, 177 (18.0%) had no outpatient health care exposure, and 400 (40.7%) had low-level outpatient health care exposure. Thirty-one percent of patients without antibiotic exposure received proton pump inhibitors. Patients having CDI with no or low-level outpatient health care exposure were more likely to be exposed to infants younger than 1 year (P = .04) and to household members with active CDI (P = .05) compared with those having high-level outpatient health care exposure. No association between food exposure or animal exposure and level of outpatient health care exposure was observed. North American pulsed-field gel electrophoresis (NAP) 1 was the most common (21.7%) strain isolated; NAP7 and NAP8 were uncommon (6.7%).

Conclusions and relevance: Most patients with community-associated CDI had recent outpatient health care exposure, and up to 36% would not be prevented by reduction of antibiotic use only. Our data support evaluation of additional strategies, including further examination of C difficile transmission in outpatient and household settings and reduction of proton pump inhibitor use.

Publication types

  • Research Support, U.S. Gov't, P.H.S.

MeSH terms

  • Adolescent
  • Adult
  • Aged
  • Aged, 80 and over
  • Ambulatory Care / statistics & numerical data
  • Anti-Bacterial Agents / therapeutic use
  • Child
  • Child, Preschool
  • Clostridioides difficile / classification
  • Clostridioides difficile / isolation & purification*
  • Community-Acquired Infections / epidemiology
  • Drug Utilization / statistics & numerical data
  • Electrophoresis, Gel, Pulsed-Field / statistics & numerical data
  • Enterocolitis, Pseudomembranous / epidemiology*
  • Enterocolitis, Pseudomembranous / transmission
  • Feces / microbiology
  • Female
  • Histamine H2 Antagonists / therapeutic use
  • Hospitalization / statistics & numerical data
  • Humans
  • Immunosuppressive Agents / therapeutic use
  • Infant
  • Male
  • Middle Aged
  • Molecular Typing
  • Multivariate Analysis
  • Population Surveillance*
  • Proton Pump Inhibitors / therapeutic use
  • United States / epidemiology
  • Young Adult


  • Anti-Bacterial Agents
  • Histamine H2 Antagonists
  • Immunosuppressive Agents
  • Proton Pump Inhibitors