Investigation of community-associated Clostridium (Clostridioides) difficile infections in the Asia-Pacific region

Abstract

Background: Clostridium (Clostridioides) difficile is the most common cause of nosocomial diarrhoeal infections in high-income countries, however, community-associated (CA)-C. difficile infections (CDIs) now make up about 30% of all CDIs. Antimicrobial use and advanced age are the most common risk factors for CDI, although CA-CDI often affects younger patients. Little is currently known about the epidemiology of CA-CDI in the Asia-Pacific region. Methods and materials: A prospective study of CDI in hospital inpatients was conducted from March 2014 to January 2015 at 70 sites in 13 Asia-Pacific countries. Recruited cases (n = 600) had ≥3 episodes of diarrhoea in a 24 h period and diagnosis of CDI by toxin enzyme immunoassay, cell culture cytotoxicity assay, real-time PCR or toxigenic culture. Demographic and clinical data were collected, stool samples were cultured for C. difficile, and PCR ribotyping of isolates was performed. Proportions were compared by Chi-square test for CA-CDI (no hospitalisation in previous 12 w) vs hospital-associated (HA)-CDI (discharged from hospital in previous 4 w) cases identified in the study. A generalised linear mixed model regression was performed to find risk factors for CA-CDI. Results: HA-CDI was determined in 350 (65.4%) and CA-CDI in 74/535 (13.8%) cases aged ≥2 y. The median age of CA-CDI cases was lower at 53.5 y vs 66.0 y in HA-CDI cases (p < 0.01). Recent antimicrobial use was less frequent among CA-CDI cases (63.5% vs 80.0%, p < 0.01) while death and recurrent CDI were rarer outcomes (1.7% vs 5.8% and 5.0% vs 9.8%, p > 0.05). The most common ribotypes (RTs) causing CA-CDI were RT 017 (17.0%) followed by RTs 012 (14.6%, primarily in China), 014/020 (9.8%, predominantly in Australia and China), and RTs 002, 018 and 070 (all 7.3%). Inflammatory bowel disease (odds ratio [OR] 5.26, p < 0.05) and infection with RTs 012 (OR 5.44, p < 0.05) and 070 (OR 6.19, p < 0.05) were significantly associated with CA-CDI. Conclusion: CA-CDI patients in the Asia-Pacific region were significantly younger and had less frequent history of antimicrobial use compared to HA-CDI patients. RTs 012 and 070 were associated with CA-CDI, highlighting a need for investigation of community-based reservoirs of C. difficile including animals and outdoor environments.