Epidemiology

Analysis of data sourced from the USA reveals the susceptibility of the elderly already in a healthcare setting to C. difficile infections occurring as a result of current healthcare practice issues, primarily the overuse of antibiotics and other limitations in disease control. Data shows that two thirds of C. difficile infections (CDI) occur in healthcare settings, causing 500,000 cases and 29,000 deaths (Turner et al., 2020).    

A C. difficile infection is distinguished by the disturbance of the gut microbiome due to the introduction of antibiotics. With patients in hospital likely to be on a course of antibiotics for some other condition, a significant number of hospital acquired CDI has a ~5% mortality rate in patients, as well as being a leading cause of hospital associated diarrhoea and colitis admission worldwide (De Roo et al., 2020).

In Europe, C. difficile causes approximately 123,997 cases annually (Czepiel et al., 2021), highlighting its burden on local public health. In England alone, the UK Health Security Agency reported that in 2022-23 there were approximately 15,583 cases of CDI (Graph 1) (UKHSA., 2024). As per the below graph, data could be extrapolated to reflect the approach of a plateau in cases, suggesting continuous inconsistencies in general practice.

Upon considering more virulent strains like the ribotype 027, which sees higher infection and mortality rates, the figures are considerably more concerning (Roo et al., 2020). The peak of this strain occurred in 2007, with the UK strictly regulating and reforming its disease control procedures in order to control the spread. As per the UKHSA data, the measures were initially successful in controlling the number of cases, the evident current plateauing of cases further reinforces the argument that current methods of disease control are insufficient.

Graph 1., Cases of C. difficile in England, 2007-2023 (UKHSA., 2024)

In 2009, there were 25,604 recorded cases of CDI in England, with data from the UKHSA indicating a significant decrease in cases in the early 2010s, though the rate of decrease in cases has plateaued in recent years (Graph 1) (UKHSA., 2024). This plateau, indicative of a shift in the epidemiological landscape, suggests that initial disease control methods were effective but further reductions in cases are limited, possibly due to insufficient methods or antibiotic misuse. This data suggests that ongoing surveillance of CDI trends will be essential to refine public health strategies.  

C. difficile contamination primarily occurs via the faecal-oral pathway, with C. difficile spores having high resistance to environmental conditions. Moreover, the use of three antibiotics in tandem; fluoroquinolones, clindamycin, and cephalosporins affect the balance of the gut microbiome, ensuring optimal conditions for C. difficile (Slimings et al., 2021). Epidemiological control of C. difficile will require improvement of current infection control practices in a dynamic manner which can keep up with changing trends and CDI incidences. Upon admission, patients should ideally be isolated in quarantined infection wards, full PPE worn and surfaces must be sterilised frequently to eliminate spores.

 

References

Cruz-López, A.;, Morfin-Otero, F.;, Maldonado-Garza, R.;, Garza-González, H.J.;, An, E., Martínez-Meléndez, A., Cruz-López, F., Morfin-Otero, R., Maldonado-Garza, H.J., Garza-González, E., 2022. An Update on Clostridioides difficile Binary Toxin. Toxins 2022, Vol. 14, Page 305 14, 305.

Czepiel, J., Krutova, M., Mizrahi, A., Khanafer, N., Enoch, D.A., Patyi, M., Deptuła, A., Agodi, A., Nuvials, X., Pituch, H., Wójcik-Bugajska, M., Filipczak-Bryniarska, I., Brzozowski, B., Krzanowski, M., Konturek, K., Fedewicz, M., Michalak, M., Monpierre, L., Vanhems, P., Gouliouris, T., Jurczyszyn, A., Goldman-Mazur, S., Wultańska, D., Kuijper, E.J., Skupień, J., Biesiada, G., Garlicki, A., 2021. Mortality Following Clostridioides difficile Infection in Europe: A Retrospective Multicenter Case-Control Study. Antibiotics 10, 299.

De Roo, A.C., Regenbogen, S.E., De Roo, A.C., Regenbogen, S.E., 2020a. Clostridium difficile Infection: An Epidemiology Update. Clin Colon Rectal Surg 33, 49–57.

Fingertips | Department of Health and Social Care [WWW Document], 2024 URL https://fingertips.phe.org.uk/search/difficile#page/4/gid/1/pat/159/par/K02000001/ati/15/are/E92000001/iid/91902/age/205/sex/4/cat/-1/ctp/-1/yrr/1/cid/4/tbm/1

Lim, S.C., Knight, D.R., Riley, T. V., 2020. Clostridium difficile and One Health. Clinical Microbiology and Infection 26, 857–863.

Slimings, C., Riley, T. V., 2021. Antibiotics and healthcare facility-associated Clostridioides difficile infection: systematic review and meta-analysis 2020 update. Journal of Antimicrobial Chemotherapy 76, 1676–1688.

Turner, N.A., Anderson, D.J., 2020. Hospital Infection Control: Clostridioides difficile. Clin Colon Rectal Surg 33, 98. https://doi.org/10.1055/S-0040-1701234

UKHSA Clostridioides difficile: guidance, data and analysis - GOV.UK [WWW Document], 2024. URL https://www.gov.uk/government/collections/clostridium-difficile-guidance-data-and-analysis