JAC Advance Access originally published online on April 22, 2008
Journal of Antimicrobial Chemotherapy 2008 62(2):388-396; doi:10.1093/jac/dkn163
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Original research |
A case–control study of community-associated Clostridium difficile infection
1 Department of Microbiology, Leeds Teaching Hospitals, Old Medical School, Leeds LS1 3EX, UK 2 University of Leeds, Leeds, UK 3 Department of Microbiology, Royal Cornwall Hospital, Truro, Cornwall, UK 4 Department of Microbiology, Sunderland Royal Hospital, Sunderland, UK
Received 23 January 2008; returned 19 February 2008; revised 5 March 2008; accepted 19 March 2008
* Correspondence address. Department of Microbiology, Old Medical School, Leeds General Infirmary and University of Leeds, Leeds LS1 3EX, UK. Tel: +44-113-3926818; Fax: +44-113-3435649; E-mail: mark.wilcox{at}leedsth.nhs.uk
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 
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 (
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.
Keywords: antibiotics , diarrhoea , community-acquired