Patient and strain characteristics associated with clostridium difficile transmission and adverse outcomes

Jessica S.H. Martin, David W. Eyre, Warren N. Fawley, David Griffiths, Kerrie Davies, Damian P.C. Mawer, Timothy E.A. Peto, Derrick W. Crook, A. Sarah Walker, Mark H. Wilcox*

*Corresponding author for this work

Research output: Contribution to journalArticlepeer-review

17 Citations (Scopus)


Background No study has used whole-genome sequencing (WGS) to investigate risk factors for Clostridium difficile (CD) transmission between cases, or assessed the impact of recent acquisition on patient outcome. Methods This 20 month retrospective cohort study included consecutive cytotoxin-positive diarrheal samples, which underwent culture, ribotyping, and WGS (Illumina). Sequenced isolates were compared using single nucleotide variants (SNVs). Independent predictors of acquisition from another case, onward transmission, 120-day recurrence, and 30-day mortality were identified using logistic regression with backwards elimination. Results Of 660 CD cases, 640 (97%) were sequenced, of which 567 (89%) shared a ribotype with a prior case, but only 227 (35%) were ≤2 SNVs from a prior case, supporting recent acquisition. Plausible (<2 SNVs) recent ward-based acquisition from a symptomatic case was more frequent in certain ribotypes; 64% (67/105) for ribotype-027 cases, compared with 11% (6/57) for ribotype-078. Independent risk factors (adjusted P <.05) for CD acquisition included older age, longer inpatient duration, and ribotype; these factors, and male sex, increased onward transmission. Patients with a plausible donor had a greater risk of recurrence (adjusted P =.001) and trended towards greater 30-day mortality (adjusted P =.06). Ribotype had no additional mortality or recurrence impact after adjusting for acquisition (P >.1). Conclusions Greater transmission of certain lineages suggests CD may have different reservoirs and modes of transmission. Acquiring CD from a recent case is associated with poorer clinical outcomes. Clinical characteristics associated with increased healthcare-associated CD transmission could be used to target preventative interventions.

Original languageEnglish
Pages (from-to)1379-1387
Number of pages9
JournalClinical Infectious Diseases
Issue number9
Publication statusPublished - 15 Oct 2018

Bibliographical note

Publisher Copyright:
© The Author(s) 2018. Published by Oxford University Press for the Infectious Diseases Society of America.


  • Clostridium difficile
  • outcome
  • whole-genome sequencing


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