Delivering a Healthy WA
Disease WAtch

Community-associated Clostridium difficile infection – an emerging issue

Enhanced surveillance by the Healthcare Associated Infection Unit (HAIU) suggests community-associated Clostridium difficile infection (CA-CDI) may be a growing concern.

Clostridium difficile infection (CDI) has traditionally been considered almost exclusively a nosocomial or ‘healthcare-associated’ infection (HAI)1. Recent literature, however, suggests that a changing epidemiology is emerging, with an increase in community cases being observed, and disease occurring in individuals who lack any of the classical risk factors of being in an older age group, history of antibiotic use, and recent hospitalisation.1

Further research is being undertaken to quantify the burden of CDI in the community.

Clostridium difficile is a spore-forming, Gram-positive, anaerobic bacillus, which is a frequent cause of antibiotic-associated diarrhoea, especially among hospitalised patients3.The spectrum of disease caused by CDI can range from mild diarrhoea to severe conditions such as fulminant colitis and toxic megacolon which can result in death3,4.

Western Australian rates of hospital-identified CDI (HI-CDI) are reported by the Department of Health via Healthcare Infection Surveillance WA (HISWA). The latest data show an increase in aggregate rates since reporting commenced in January 2010 (Figure 1). HI-CDI include all cases identified at a healthcare facility, including inpatients, outpatients and those attending the emergency department. This definition does not differentiate between infections acquired in hospital and those acquired in the community, but rather reflects the total burden of cases identified at WA healthcare facilities.

Figure 1 – Hospital-identified Clostridium difficile infection rates, by hospital group

Enhanced surveillance undertaken by the HAIU recently, separated HI-CDI into healthcare associated and community associated cases, using the Australian Commission on Safety and Quality in Healthcare (ACSQHC) definition 5. The enhanced surveillance data confirmed that CA-CDI represented a significant proportion of CDI identified by WA hospitals (Figure 2). The true burden of CA-CDI is unknown because the data did not include cases identified in general practice. As such, HI-CDI identifies only a fraction of the true CA-CDI burden.

Further research is underway to estimate the total burden of CA-CDI in Western Australia. As the data suggest that CA-CDI may be a growing concern, C. difficile should be considered a possible cause of infectious diarrhoea in patients presenting to general practice, especially those with a recent history of antibiotic exposure.

Figure 2 – Community-associated-Clostridium difficile infection (CA-CDI) and hospital-associated Clostridium difficile infection (HA-CDI) cases reported to the Hospital Infection Surveillance Western Australia (HISWA), 2010 to 2012


  1. Pituch H. Clostridium difficile is no longer just a nosocomial infection or an infection of adults. International Journal of Antimicrobial Agents. 2009;33:S42–S5.
  2. Kuntz JL, Chrischilles EA, Pendergast JF, Herwaldt LA, Polgreen PM. Incidence of and risk factors for community-associated Clostridium difficile infection: a nested case-control study. BMC Infect Dis. 2011;11:194. Epub 2011/07/19.
  3. Barbut F, Petit J-C. Epidemiology of Clostridium difficile-associated infections. Clinical Microbiology Infections. 2001;7:405–10.
  4. Williams OM, Spencer RC. The management of Clostridium difficile infection. British Medical Bulletin. 2009;91(1):87–110.
  5. Australian Commission on Safety and Quality in Healthcare (ACSQHC). Implementation guide for surveillance of Clostridium difficile infection. Consultation Edition. 2011. Commonwealth of Australia: Canberra.

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