Community-acquired Clostridium Difficile Infection Research Articles

Occurrence of Clostridium difficile in two types of wastewater treatment plants.

Wastewater is a potential environmental source of Clostridium difficile, although a direct link with community-acquired C. difficile infection (CA-CDI) in humans has not yet been established. The present study was performed to determine the occurrence of C. difficile in two types of wastewater treatment plants (WWTPs) in Isfahan, Iran. A total of 95 samples were taken from a conventional activated sludge treatment plant and a waste stabilization ponds system, and analyzed for the presence of C. difficile. C. difficile was found in 13.6% (3/22) of digested sludge samples. However, no C. difficile was detected in inlet and outlet samples or in raw sludge of activated sludge. C. difficile was also detected in 5% (2/40) of the samples from waste stabilization ponds. Polymerase chain reaction (PCR) analysis showed that all strains of C. difficile detected were toxigenic (tcdB gene positive). This study shows that C. difficile was present in WWTPs, which might constitute a potential source of community-acquired C. difficile infection.

PIN62 - Projected Cost Savings of Introducing fecal Microbiota Transplant Treatment for Clostridium Difficile Infection In Canada

To project the cost savings of introducing Fecal Microbiota Transplant (FMT) treatment for Clostridium difficile infection (CDI) as compared to current practice, by age, and three major subpopulations; hospitals, long-term care facilities (LTCF), and communities. We modified our existing CDI decision analytic model to project the total cost savings of FMT as compared to current antibiotic treatment for CDI over five years (2015-2019), by integrating current annual trends in CDI, and population projections for Canada, by age, gender, and three major subpopulations. To estimate current annual trends in CDI we conducted a systematic analysis of the latest provincial and federal CDI data in Canada. Over the next five years, CDI treatment with FMT is estimated to result in a potential cost savings of $300.4 M as compared to current practice. We projected 20,700 fewer cases of CDI in the FMT treatment arm, due to fewer recurrences for FMT. The recurrence rates for current antibiotic treatment were estimated at 25.3% and 35.9% for first and second recurrences, respectively. The recurrence rate for FMT was 10.4%. Over 90% of the cost savings for FMT as compared to antibiotic treatment are for ages 60 and over, with $127.3 M for ages 60 to 79 years, and $148.3 M for ages 80 and over. By subpopulation, over the next five years FMT would result in a potential cost savings of $216.5 M for hospital-acquired CDI (HA-CDI), and $68.7 M for community-acquired CDI (CA-CDI). Introducing FMT could result in a substantial cost savings over the next five years in Canada. As the Canadian population ages, and the numbers of CDI cases among the elderly might grow, FMT holds the promise of higher potential cost savings.

The economic impact of Clostridium difficile infection: a systematic review.

With Clostridium difficile infection (CDI) on the rise, knowledge of the current economic burden of CDI can inform decisions on interventions related to CDI. We systematically reviewed CDI cost-of-illness (COI) studies. We performed literature searches in six databases: MEDLINE, Embase, the Health Technology Assessment Database, the National Health Service Economic Evaluation Database, the Cost-Effectiveness Analysis Registry, and EconLit. We also searched gray literature and conducted reference list searches. Two reviewers screened articles independently. One reviewer abstracted data and assessed quality using a modified guideline for economic evaluations. The second reviewer validated the abstraction and assessment. We identified 45 COI studies between 1988 and June 2014. Most (84%) of the studies were from the United States, calculating costs of hospital stays (87%), and focusing on direct costs (100%). Attributable mean CDI costs ranged from $8,911 to $30,049 for hospitalized patients. Few studies stated resource quantification methods (0%), an epidemiological approach (0%), or a justified study perspective (16%) in their cost analyses. In addition, few studies conducted sensitivity analyses (7%). Forty-five COI studies quantified and confirmed the economic impact of CDI. Costing methods across studies were heterogeneous. Future studies should follow standard COI methodology, expand study perspectives (e.g., patient), and explore populations least studied (e.g., community-acquired CDI).

Community-acquired Clostridium difficile infection and Australian food animals

Clostridium difficile is an anaerobic Gram positive spore-forming bacterium, the leading cause of infectious diarrhoea (C. difficile infection; CDI) in hospitalised humans. The assumption that CDI is primarily a hospital-acquired infection is being questioned. Community-acquired CDI (CA-CDI) is increasing1 particularly in groups previously considered at low risk2,3. In Australia, CA-CDI rates doubled during 2011 and increased by 24% between 2011 and 20124. Two potentially high-risk practices in Australian food animal husbandry may present a risk for CA-CDI: slaughtering of neonatal animals for food, and effluent recycling to agriculture.

Occurrence of Toxigenic Clostridium difficile in Louisiana Oysters (<i>Crassostrea virginica</i>) and Environmental Waters

Clostridium difficile infection (CDI) was generally considered as a hospital-associated disease; however, recent community-acquired CDI has raised the concerns regarding the transmission of the pathogen through environmental sources. Limited data are available regarding the presence of C. difficile in food and water. In this study, oysters (Crassostrea virginica) and the harvest water collected from the commercial harvesting areas along the Louisiana Gulf Coast as well as the influent and effluent of a municipal treatment plant in New Orleans, LA were analyzed for toxigenic C. difficile. The bacterium was isolated from 47.37% (9/19) of oysters and 37.5% (3/8) of harvest water samples. Toxigenic C. difficile were also detected in all the wastewater influent and effluent samples. All the isolates harbored the gene tcdB encoding the virulence factor toxin B. Further PCR-ribotyping showed that the C. difficile isolated from the oysters and harvest water differed from the wastewater isolates. However, similar ribotypes were found in oysters and the surrounding harvest water. We found that oysters growing in contaminated water could bioaccumulate toxigenic C. difficile and pose a health risks by serving as a vehicle for the transmission of the pathogen to humans.

Comorbidities, Exposure to Medications, and the Risk of Community-Acquired Clostridium difficile Infection: a systematic review and meta-analysis.

Clostridium difficile infection (CDI) has been extensively described in healthcare settings; however, risk factors associated with community-acquired (CA) CDI remain uncertain. This study aimed to synthesize the current evidence for an association between commonly prescribed medications and comorbidities with CA-CDI. A systematic search was conducted in 5 electronic databases for epidemiologic studies that examined the association between the presence of comorbidities and exposure to medications with the risk of CA-CDI. Pooled odds ratios were estimated using 3 meta-analytic methods. Subgroup analyses by location of studies and by life stages were conducted. Twelve publications (n=56,776 patients) met inclusion criteria. Antimicrobial (odds ratio, 6.18; 95% CI, 3.80-10.04) and corticosteroid (1.81; 1.15-2.84) exposure were associated with increased risk of CA-CDI. Among the comorbidities, inflammatory bowel disease (odds ratio, 3.72; 95% CI, 1.52-9.12), renal failure (2.64; 1.23-5.68), hematologic cancer (1.75; 1.02-5.68), and diabetes mellitus (1.15; 1.05-1.27) were associated with CA-CDI. By location, antimicrobial exposure was associated with a higher risk of CA-CDI in the United States, whereas proton-pump inhibitor exposure was associated with a higher risk in Europe. By life stages, the risk of CA-CDI associated with antimicrobial exposure greatly increased in adults older than 65 years. Antimicrobial exposure was the strongest risk factor associated with CA-CDI. Further studies are required to investigate the risk of CA-CDI associated with medications commonly prescribed in the community. Patients with diarrhea who have inflammatory bowel disease, renal failure, hematologic cancer, or diabetes are appropriate populations for interventional studies of screening.

1794Appropriate Antibiotic Therapy is Associated with Reduced Risk of Community Acquired Clostridium difficile Infection

1794Appropriate Antibiotic Therapy is Associated with Reduced Risk of Community Acquired Clostridium difficile Infection

Vitamin D deficiency is associated with community-acquired clostridium difficile infection: a case-control study.

BackgroundClostridium difficile infection (CDI) is increasingly recognized as an important community acquired pathogen causing disease (CA-CDI). Vitamin D [25(OH)D] has immune modulatory effects and plays an important role in intestinal immunity. The role of vitamin D in CA-CDI has not been examined previously.MethodsThis was a single referral center case–control study. Cases comprised of all patients with CA-CDI who had a serum 25(OH)D measured within 12 months prior to infection. Controls were drawn from patients who had 25(OH)D checked and matched based on age, gender, race and health status. Serum 25(OH)D was stratified as < 15 ng/mL, 15-30 ng/mL or > 30 ng/mL. Regression models adjusting for potential confounders were used to define independent association between vitamin D and CA-CDI.ResultsWe identified 58 matched case–control pairs (66% women; 85% Caucasian). The mean age was 62 years. The mean serum 25(OH)D level was significantly lower in CA-CDI cases compared to controls (28.5 ng/mL vs. 33.8 ng/mL, p = 0.046). Cases had higher rate of antibiotic exposure and more comorbidity. Serum 25(OH)D < 15 ng/mL was associated with an increased risk of CA-CDI on univariate (Odds ratio (OR) 5.10, 95% confidence interval (CI) 1.51 – 17.24) and multivariate analysis (OR 3.84, 95% CI 1.10 – 13.42). Vitamin D levels between 15-30 ng/mL did not modify disease risk.ConclusionsLow serum 25(OH)D < 15 ng/mL was associated with increased risk of CA-CDI. This suggests vitamin D may have a role in determining susceptibility to CA-CDI.

Low Serum Vitamin D is Associated With Increased Risk of Community-Acquired Clostridium difficile Infection

Introduction:Clostridium difficile infection (CDI) is increasingly recognized as an important community-acquired pathogen causing disease in patients with no recent healthcare contact (CA-CDI). Vitamin D [25(OH)D] has immune modulatory effects and plays an important role in intestinal immunity. The role of vitamin D in CA-CDI has not been examined previously, but may offer insights into pathogenesis and prevention. Methods: This was a single center case-control study. Cases comprised of patients with a positive C. difficile toxin assay who had a serum 25(OH)D measured within 12 months prior or within 14 days of CDI diagnosis. The analysis was restricted to community-acquired cases diagnosed as an outpatient or within 48 hours of inpatient status and no recent hospitalization or long-term care facility stay within 30 days prior to diagnosis. Controls were drawn from patients who had 25(OH)D checked and matched based on age, gender, race, and health status. Serum 25(OH)D was stratified as <15 ng/mL, 15-30 ng/mL or > 30 ng/mL. Regression models adjusting for potential confounders including comorbidity, season, and antibiotic use were used to define independent effect of serum 25(OH)D on risk of CA-CDI. Results: We identified 58 matched case-control pairs. Two-thirds were women and a majority was Caucasian with a mean age of 62 years. The mean serum 25(OH)D level was significantly lower in CA-CDI cases compared to controls (28.5 ng/mL vs. 33.8 ng/mL, p=0.046) (Figure 1). Cases had significantly higher rate of antibiotic exposure (odds ratio [OR] 10.8; 95% confidence interval [CI] 4.6-25.8), lower serum albumin (mean 3.2 vs. 4.3), and significantly more comorbiditty. Serum 25(OH)D below 15 ng/mL was associated with a significantly increased risk of CA-CDI on univariate (OR 3.9; 95% CI 1.1-13.4) and multivariate analysis adjusting for comorbidity and season of measurement (OR 3.84; 95% CI 1.10-13.42). Serum 25(OH)D levels between 15-30 ng/mL did not modify disease risk. Additional adjustment for antibiotic use only weakly attenuated the effect (p=0.066).Figure 1: Serum 25(OH)D levels in Clostridium difficile cases and controls.Conclusion: Low serum 25(OH)D < 15ng/mL was associated with increased risk of CA-CDI. This suggests vitamin D may have a role in determining susceptibility to CA-CDI, and offers intriguing insights into pathogenesis and potential for disease prevention. Disclosure - Dr. Ananthakrishnan - Scientific advisory board, Cubist pharmaceuticals.

Community-acquired Clostridium difficile infection: an increasing public health threat

There has been a startling shift in the epidemiology of Clostridium difficile infection over the last decade worldwide, and it is now increasingly recognized as a cause of diarrhea in the community. Classically considered a hospital-acquired infection, it has now emerged in populations previously considered to be low-risk and lacking the traditional risk factors for C. difficile infection, such as increased age, hospitalization, and antibiotic exposure. Recent studies have demonstrated great genetic diversity for C. difficile, pointing toward diverse sources and a fluid genome. Environmental sources like food, water, and animals may play an important role in these infections, apart from the role symptomatic patients and asymptomatic carriers play in spore dispersal. Prospective strain typing using highly discriminatory techniques is a possible way to explore the suspected diverse sources of C. difficile infection in the community. Patients with community-acquired C. difficile infection do not necessarily have a good outcome and clinicians should be aware of factors that predict worse outcomes in order to prevent them. This article summarizes the emerging epidemiology, risk factors, and outcomes for community-acquired C. difficile infection.

Epidemiology and outcomes of community-acquired Clostridium difficile infections in Medicare beneficiaries.

The incidence of community-acquired Clostridium difficile (CACD) is increasing in the United States. Many CACD infections occur in the elderly, who are predisposed to poor outcomes. We aimed to describe the epidemiology and outcomes of CACD in a nationally representative sample of Medicare beneficiaries. We queried a 5% random sample of Medicare beneficiaries (2009-2011 Part A inpatient and Part D prescription drug claims; n= 864,604) for any hospital admission with a primary ICD-9 diagnosis code for C difficile (008.45). We examined patient sociodemographic and clinical characteristics, preadmission exposure to oral antibiotics, earlier treatment with oral vancomycin or metronidazole, inpatient outcomes (eg, colectomy, ICU stay, length of stay, mortality), and subsequent admissions for C difficile. A total of 1,566 (0.18%) patients were admitted with CACD. Of these, 889 (56.8%) received oral antibiotics within 90 days of admission. Few were being treated with oral metronidazole (n= 123 [7.8%]) or vancomycin (n= 13 [0.8%]) at the time of admission. Although 223 (14%) patients required ICU admission, few (n= 15 [1%]) underwent colectomy. Hospital mortality was 9%. Median length of stay among survivors was 5 days (interquartile range 3 to 8 days). One fifth of survivors were readmitted with C difficile, with a median follow-up time of 393 days (interquartile range 129 to 769 days). Nearly half of the Medicare beneficiaries admitted with CACD have no recent antibiotic exposure. High mortality and readmission rates suggest that the burden of C difficile on patients and the health care system will increase as the US population ages. Additional efforts at primary prevention and eradication might be warranted.

Is obesity a risk factor for Clostridium difficile infection?

The epidemiology of Clostridium difficile infection (CDI) has become an important area of investigation, especially in light of the global increase in both hospital-acquired (HA) and community-acquired (CA) CDI. Recently, obesity was found to be associated with CDI and was suggested to represent an independent risk factor for it. We undertook a case-control study to examine obesity as an exposure for both HA and CA cases in adults (age ≥ 18 years) admitted to a tertiary, university-affiliated, acute care medical facility in the northeastern United States. During the period January 2012-July 2013, we examined cross-sectional BMI data on 189 cases of CDI and 189 contemporaneous age and gender-matched controls. We were unable to detect a statistically significant difference between the two groups; in fact, the BMI values for both groups were substantially equivalent (cases: median=26.5 kg/m, IQR: 22.1-32.5; controls: median=26.0, IQR: 22.7-31.0; p=0.696). Odds ratios (and 95% confidence intervals), evaluated at BMI of 25, 30 and 35 kg/m(2), did not demonstrate statistical significance. These data suggest that obesity, as described by BMI, may not be a risk factor for CDI in all populations.

Newer Diagnostic Methods in Clostridium difficile Infection

Clostridium difficile infection (CDI) is a public health problem causing severe morbidity and mortality. The clinical presentations of CDI vary from asymptomatic carriage to the full blown pseudo membranous colitis (PMC). With the arrival of the hyper virulent NAP1/BI/027 C. difficile strain, increased incidence of more severe clinical conditions inclusive of PMC, toxic megacolon and intestinal perforation are being reported from the West. Additionally, the recognition of community-acquired CDI signals the presence of several risk factors. Accurate diagnosis of CDI is essential for ongoing epidemiology, optimal treatment and prevention but continues to be challenging. During the past 30 years no standard laboratory test for CDI diagnosis has been clearly established. Diagnostic approaches for CDI are based on several aspects. Clinically the signs and symptoms are watery or bloody diarrhea, abdominal cramps, fever, leukocytosis, etc. PMC can be diagnosed endoscopically as multiple yellow-white friable plaques, a few centimeters in size, attached to the underlying mucosa. Computed tomography scan findings does not help diagnosis, but may help in initiating specific therapy against CDI. Culture can be used for epidemiological and antibiogram purposes during outbreaks. Tissue cultures, enzyme immunoassays and molecular assays are useful to detect C. difficile toxins. Glutamate dehydrogenase test helps to screen out a large number of samples. Toxigenic culture is based on the isolation of C. difficile in culture and then detecting its toxigenic status. The implications of a false negative or a false positive test can lead to disastrous consequence. There are currently two reference assays for the diagnosis of CDI with different targets: the cytotoxicity assay that detects free toxins and the toxigenic culture which detects the organism with the potential to produce toxin. CDI diagnostic testing is an important issue and clinical laboratory professionals should use the assays which give the best performance for the detection of CDI.

Efficacy and safety of, and patient satisfaction with, colonoscopic-administered fecal microbiota transplantation in relapsing and refractory community- and hospital-acquired Clostridium difficile infection.

To report the efficacy and safety of, and patient satisfaction with, colonoscopic fecal microbiota transplantation (FMT) for community- and hospital-acquired Clostridium difficile infection (CDI). A retrospective medical records review of patients who underwent FMT between July 1, 2012 and August 31, 2013 was conducted. A total of 22 FMTs were performed on 20 patients via colonoscopy. The patients were divided into 'community-acquired' and 'hospital-acquired' CDI. Telephone surveys were conducted to determine procedure outcome and patient satisfaction. Primary cure rate was defined as resolution of diarrhea without recurrence within three months of FMT, whereas secondary cure rate described patients who experienced resolution of diarrhea and return of normal bowel function after a second course of FMT. Nine patients met the criteria for community-acquired CDI whereas 11 were categorized as hospital-acquired CDI. A female predominance in the community-acquired group (88.89% [eight of nine]) was found (P=0.048). The primary cure rate was 100% (nine of nine) and 81.8% (nine of 11 patients) in community- and hospital-acquired CDI groups, respectively (P=0.189). Two patients in the hospital-acquired group had to undergo a repeat FMT for persistent symptomatic infection; the secondary cure rate was 100%. During the six-month follow-up, all patients were extremely satisfied with the procedure and no complications or adverse events were reported. FMT was a highly successful and very acceptable treatment modality for treating both community- and hospital-acquired CDI.

Community-Acquired Clostridium difficile Infection: An Emerging Problem

The incidence of Clostridium difficile infection (CDI) has been increasing in recent years with a trend towards higher hospitalization and mortality rates. Well-known risk factors such as age and antimicrobial usage have been known to play a role in the development of both hospital-acquired and community-acquired CDI but other potentially novel risk factors such as proton pump inhibitor usage, close contact with a colonized individual and zoonotic or foodborne transmission may contribute to community-acquired cases. There also have been new developments in management of CDI with the use of donor feces for treatment of those with recurrent disease and in the use of probiotics as a strategy for preventing CDI.

A unique strain of community-acquired Clostridium difficile in severe complicated infection and death of a young adult

BackgroundClostridium difficile is the major cause of nosocomial antibiotic-associated diarrhoea with the potential risk of progressing to severe clinical outcomes including death. It is not unusual for Clostridium difficile infection to progress to complications of toxic megacolon, bowel perforation and even Gram-negative sepsis following pathological changes in the intestinal mucosa. These complications are however less commonly seen in community-acquired Clostridium difficile infection than in hospital-acquired Clostridium difficile infection. To the best of our knowledge, this was the first case of community-acquired Clostridium difficile infection of its type seen in Jamaica.Case presentationWe report a case of a 22-year-old female university student who was admitted to the University Hospital of the West Indies, Jamaica with a presumptive diagnosis of pseudomembranous colitis PMC. She presented with a 5-day history of diarrhoea following clindamycin treatment for coverage of a tooth extraction due to a dental abscess. Her clinical condition deteriorated and progressed from diarrhoea to toxic megacolon, bowel perforation and Gram-negative sepsis. Clostridium difficile NAP12/ribotype 087 was isolated from her stool while blood cultures grew Klebsiella pneumoniae. Despite initial treatment intervention with empiric therapy of metronidazole and antibiotic clearance of Klebsiella pneumoniae from the blood, the patient died within 10 days of hospital admission.ConclusionsWe believe that clindamycin used for coverage of a dental abscess was an independent risk factor that initiated the disruption of the bowel micro-flora, resulting in overgrowth of Clostridium difficile NAP12/ribotype 087. This uncommon strain, which is the same ribotype (087) as ATCC 43255, was apparently responsible for the increased severity of the infection and death following toxic megacolon, bowel perforation and pseudomembranous colitis involving the entire large bowel. K. pneumoniae sepsis, resolved by antibiotic therapy was secondary to Clostridium difficile infection. The case registers community-acquired Clostridium difficile infection as producing serious complications similar to hospital-acquired Clostridium difficile infection and should be treated with the requisite importance.

Shock séptico debido a la infección por Clostridium difficile adquirida en la comunidad. Estudio de un caso y revisión de la literatura

The epidemiology of Clostridium difficile infection has changed in the past decade. The incidence rate of community acquired cases has increased in patients with no typical risk factors. We present a patient who was diagnosed with community-acquired Clostridium difficile infection who presented with acute abdominal pain, and subsequently developed acute renal failure and septic shock. We describe the diagnosis, treatment and outcome and brief review of the literature.

Clostridium difficile infections: do we know the real dimensions of the problem?

Clostridium difficile infection (CDI) is the primary cause of nosocomial diarrhoea in industrialised countries, usually occurring as a complication of antibiotic therapy in elderly patients. Landmark events contributed to boosting interest in CDI over the last 10 years, including the emergence of unusually severe and recurrent CDI due to the NAP1/BI/027 strain, as well as reports suggesting that CDI is also significantly encountered in patients previously considered at no risk, such as community-acquired CDI in patients with no recent antibiotic use, or CDI during pregnancy. Despite this growing interest from the medical community, we do not know the real dimensions of the disease for the following reasons: (i) despite comprehensive guidelines published in Europe and in the USA, most laboratories still use diagnostic tests with suboptimal sensitivity as a ‘rule-out’ test, hence a significant proportion of CDIs remain undiagnosed; (ii) use of PCR as a stand-alone test by others will probably overestimate the real incidence of CDI and jeopardise any comparison between institutions with different diagnostic procedures; and (iii) transversal studies, with optimum design and diagnostic tests, are rapidly outdated due to the dramatic changes in CDI epidemiology that may occur from one year to another. To get an accurate picture of the real dimensions of the CDI issue, we need more systematic use of an adequate and homogeneous diagnostic strategy in the field as well as the implementation of continuous monitoring of CDI incidence through surveillance programmes.

Diagnosis and Management of Clostridium difficile Infection

Clostridium difficile infection (CDI) is increasing in frequency and severity in and out of the hospital, with a high probability of recurrence after treatment. The recent literature on CDI was reviewed using PubMed to include recent publications dealing with diagnosis and therapy. Real-time polymerase chain reaction is a sensitive and useful diagnostic test for CDI but there are growing concerns of false-positive test results if the rate of CDI is low in the patient population providing samples and/or if the population being studied commonly includes people with C difficile colonization. Recommended therapy of CDI includes oral metronidazole for milder cases of CDI and oral vancomycin or fidaxomicin for more severe cases, each given for 10 days. Colectomy is being performed more frequently in patients with fulminant CDI. For treatment of first recurrences the drug used in the first bout can be used again and for second recurrences longer courses of vancomycin often are given in a tapered dose or intermittently to allow gut flora reconstitution, or other treatments including fidaxomicin may be used. Bacteriotherapy with fecal transplantation is playing an increasing role in therapy of recurrent cases. Metagenomic studies of patients with CDI during successful therapy are needed to determine how best to protect the flora from assaults from antibacterial drugs and to develop optimal therapeutic approaches. Immunotherapy and immunoprophylaxis offer opportunities to prevent CDI, to speed up recovery from CDI, and to eliminate recurrent infection. Humanized monoclonal antitoxin antibodies and active immunization with vaccines against C difficile or its toxins are both in development and appear to be of potential value.

The Epidemiology of Clostridium difficile Infection in Children: A Population-Based Study

The incidence of Clostridium difficile infection (CDI) is increasing, even in populations previously thought to be at low risk, including children. Most incidence studies have included only hospitalized patients and are thus potentially influenced by referral or hospitalization biases. We performed a population-based study of CDI in pediatric residents (aged 0-18 years) of Olmsted County, Minnesota, from 1991 through 2009 to assess the incidence, severity, treatment response, and outcomes of CDI. We identified 92 patients with CDI, with a median age of 2.3 years (range, 1 month-17.6 years). The majority of cases (75%) were community-acquired. The overall age- and sex-adjusted CDI incidence was 13.8 per 100 000 persons, which increased 12.5-fold, from 2.6 (1991-1997) to 32.6 per 100 000 (2004-2009), over the study period (P < .0001). The incidence of community-acquired CDI was 10.3 per 100 000 persons and increased 10.5-fold, from 2.2 (1991-1997) to 23.4 per 100 000 (2004-2009) (P < .0001). Severe, severe-complicated, and recurrent CDI occurred in 9%, 3%, and 20% of patients, respectively. The initial treatment in 82% of patients was metronidazole, and 18% experienced treatment failure. In contrast, the initial treatment in 8% of patients was vancomycin and none of them failed therapy. In this population-based cohort, CDI incidence in children increased significantly from 1991 through 2009. Given that the majority of cases were community-acquired, estimates of the incidence of CDI that include only hospitalized children may significantly underestimate the burden of disease in children.