Community-acquired Clostridium difficile: epidemiology, ribotype, risk factors, hospital and intensive care unit outcomes, and current and emerging therapies.

BACKGROUND: The epidemiological landscape of Clostridium difficile infection (CDI) has changed over the past 30 years. AIM: To review studies of CDI in the community setting. METHODS: Electronic databases including PubMed, MEDLINE, Embase, Google Scholar, Scopus, ClinicalTrials.gov and Cochrane Databases were searched for human studies performed between 2000 and 2017 that assessed the epidemiology, risk factors, ribotypes, hospital and intensive care unit (ICU) outcomes, and management of community-acquired CDI. In addition, references were searched manually to identify other relevant studies. FINDINGS: In total, 39 articles met the inclusion criteria. The incidence of community-acquired CDI has almost doubled in the past decade. Approximately half of all cases of CDI are attributed to community origin. Individuals who are younger, female, in the presence of infants, frequently use proton pump inhibitors or specific classes of antibiotics, or live near farms and livestock are at higher risk for community-acquired CDI. Additionally, approximately 40% of all community-acquired cases require hospitalization, where severity has been linked to hypervirulent ribotypes 027 and 078 with poor outcomes. Emerging data on treatment paradigms have led to the revision of clinical guidelines and two potential vaccines in phase three clinical trials. However, ribotype-specific responses to current treatment strategies are lacking. CONCLUSION: Community-acquired CDI represents a growing public health threat and burden on healthcare systems. A multi-disciplinary approach will be required to stem the tides.