Characterization of Healthcare-Associated and Community-Associated Clostridioides Difficile Infections Among Adults, Canada, 2015–2019

Tim Du; Kelly B. Choi; Anada Silva; George R. Golding; Linda Pelude; Romeo Hizon; Ghada N. Al-Rawahi; James Brooks; Blanda Chow; Jun C. Collet; Jeannette L. Comeau; Ian Davis; Gerald A. Evans; Charles Frenette; Guanghong Han; Jennie Johnstone; Pamela Kibsey; Kevin C. Katz; Joanne M. Langley; Bonita E. Lee; Yves Longtin; Dominik Mertz; Jessica Minion; Michelle Science; Jocelyn A. Srigley; Paula Stagg; Kathryn N. Suh; Nisha Thampi; Alice Wong; Susy S. Hota


Emerging Infectious Diseases. 2022;28(6):1128-1136. 

In This Article

Abstract and Introduction


We investigated epidemiologic and molecular characteristics of healthcare-associated (HA) and community-associated (CA) Clostridioides difficile infection (CDI) among adult patients in Canadian Nosocomial Infection Surveillance Program hospitals during 2015–2019. The study encompassed 18,455 CDI cases, 13,735 (74.4%) HA and 4,720 (25.6%) CA. During 2015–2019, HA CDI rates decreased by 23.8%, whereas CA decreased by 18.8%. HA CDI was significantly associated with increased 30-day all-cause mortality as compared with CA CDI (p<0.01). Of 2,506 isolates analyzed, the most common ribotypes (RTs) were RT027, RT106, RT014, and RT020. RT027 was more often associated with CDI-attributable death than was non-RT027, regardless of acquisition type. Overall resistance C. difficile rates were similar for all drugs tested except moxifloxacin. Adult HA and CA CDI rates have declined, coinciding with changes in prevalence of RT027 and RT106. Infection prevention and control and continued national surveillance are integral to clarifying CDI epidemiology, investigation, and control.


Clostridioides difficile is a major cause of infectious nosocomial diarrhea in high-income countries.[1] Disease severity ranges from asymptomatic colonization to fulminant colitis, sometimes leading to colectomy and death.[2] Healthcare costs attributed to C. difficile infection (CDI) are estimated to be $4.8 billion in the United States and €3 billion in Europe.[3] A study in Canada estimated 38,000 annual CDI cases and conservative estimated costs of CDN $280 million resulting from extended hospital stays and rehospitalization.[4]

The epidemiology of C. difficile has evolved markedly in the past decade.[1] Whereas CDI was once believed to be mostly healthcare-associated (HA), increased evidence points to transmission in community settings.[5,6] An estimated 40% of patients with community-associated (CA) CDI require hospitalization; 20% experience treatment failure, and 28% have recurrent CDI episodes.[7]

Several international studies have reported changes in molecular and epidemiologic characteristics of CDI in healthcare and community settings;[8–13] we investigated changes in adult CA CDI epidemiology in Canada. The Canadian Nosocomial Infection Surveillance Program (CNISP) collects standardized epidemiologic and laboratory-linked data from sentinel hospitals across Canada, currently representing 30% of all acute care beds. We previously reported a decrease in HA CDI rates during 2009–2015, associated with a reduction in ribotype (RT) 027.[1] Here, we describe findings of a multicenter study evaluating incidence, patient characteristics, outcomes, RT prevalence, and antimicrobial resistance rates for HA and CA CDI identified during 2015–2019 in hospitals participating in CNISP. We also assessed associations between predominant RTs and all-cause and CDI-attributable deaths.