Community-associated C. Difficile Infection Is Rising; Disease Carries Significant Social, Economic Burden


Clostridioides difficile infection can have a significant impact on feelings of depression and anxiety, while worsening quality of life.

Community-associated clostridioides difficile (C. difficile) infection (CDI) is increasing, according to a recent article published in BMC Infectious Diseases. New treatments should consider a variety of clinical, financial, and social outcomes of CDI and recurrent CDI (rCDI), according to the study. The authors noted that rCDI affects 35% of patients, and 60% of rCDI patients will have multiple recurrences.

“CDI has many unseen and underappreciated consequences that go far beyond gastrointestinal symptomology,” the study authors wrote in the article. “CDI and rCDI are associated with a substantial economic burden that is driven by hospitalization costs…and quality of life implications.”

CDI is the primary cause of antibiotic-associated infective diarrhea in the United States, causing nearly 30,000 annual deaths. The Centers for Disease Control (CDC) have officially identified CDI as an “urgent threat.” Patients can have asymptomatic infection or life-threatening infection. Serious symptoms include high fever, severe abdominal pain, paralytic ileus, colonic dilation (megacolon), and perforation.

The overall burden of CDI decreased 24% from 2011 and 2017, with CDI infection from the health care setting substantially decreasing by 36% to 47%. This reduction is attested to be from better antimicrobial stewardship and more aggressive CDI treatment, although treatment in the outpatient setting could benefit from antibiotic and diagnostic stewardship with more preventative measures—community-associated CDI nearly doubled in the past 10 years.

“For reference, the CDC’s surveillance program classifies cases as community-associated if the C. difficile-positive stool specimen was collected on an outpatient basis or within 3 days after hospital admission in a person with no documented overnight stay in a healthcare facility in the preceding 12 weeks,” the study authors wrote. “Given the changing epidemiology of CDI, continued efforts are required to improve infection prevention and diagnostic and antibiotic stewardship not only in inpatient settings, but also in outpatient settings.”

In addition, the clinical burden (mortality, sepsis, severe diarrhea, recurrent infections) social burden (depression, anxiety, social isolation, post-traumatic stress disorder), and economic burden (hospital readmission, inpatient costs, pharmacy costs, out-of-pocket costs) are numerous.

Clinical burden is greatly affected by rCDI, a “vicious cycle of infection–reinfection [that] impedes recovery, thereby exacerbating the burden of CDI,” the study authors wrote. rCDI can associated with risk of mortality (especially in older patients) which increases to nearly 40% by the third recurrence. Other clinical outcomes include colitis and circular shock.

At least 42% of patients with rCDI also experience anxiety about getting sick again and 26% said they feel like prisoners in their own home. The disease requires many patients to stop going to work while sick and, despite a physician’s clearance, workers also report being less productive. Investigators suggest that treatment that addresses social outcomes can improve patient quality of life.

The heavy economic burden is worth noting. Patients spend an average of $4355 in out-of-pocket costs, US inpatient costs for CDI total nearly $5 billion annually, and outpatient costs are a key cost driver. And since the COVID-19 pandemic, patient costs have risen $2000 annually. More effective models of care in the health system can combat the economic burden of CDI.

“Clinical treatment and management need to be multifaceted and consider not just pharmaceutical intervention but a holistic approach to the patient’s experience both during and after CDI, acknowledging the potential psychological and social effects as well as identifying payment assistance programs, supportive services, and work medical leave options,” the study authors wrote.


Feuerstadt P, Theriault N, Tillotson G. The burden of CDI in the United States: a multifactorial challenge. BMC Infect Dis. March 7, 2023. Accessed March 17, 2023.

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