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JAMA Netw Open. 2020 Jan 3;3(1):e1917597. doi: 10.1001/jamanetworkopen.2019.17597.

Incidence and Outcomes Associated With Clostridium difficile Infections: A Systematic Review and Meta-analysis.

Author information

Carver College of Medicine, Department of Internal Medicine, University of Iowa, Iowa City.
Division of Medical Practice, Hospital Israelita Albert Einstein, São Paulo, Brazil.
Center for Access and Delivery Research and Evaluation, Iowa City VA Health Care System, Iowa City, Iowa.
Veterans Affairs Salt Lake City Health Care System, Salt Lake City, Utah.
Department of Internal Medicine, University of Utah, Salt Lake City.
Big Data Center, China Medical University Hospital, Taichung City, Taiwan.
Division of Epidemiology and Community Health, University of Minnesota, Minneapolis.
Ruth Lilly Medical Library, Indiana University School of Medicine, Indianapolis.



An understanding of the incidence and outcomes of Clostridium difficile infection (CDI) in the United States can inform investments in prevention and treatment interventions.


To quantify the incidence of CDI and its associated hospital length of stay (LOS) in the United States using a systematic literature review and meta-analysis.

Data Sources:

MEDLINE via Ovid, Cochrane Library Databases via Wiley, Cumulative Index of Nursing and Allied Health Complete via EBSCO Information Services, Scopus, and Web of Science were searched for studies published in the United States between 2000 and 2019 that evaluated CDI and its associated LOS.

Study Selection:

Incidence data were collected only from multicenter studies that had at least 5 sites. The LOS studies were included only if they assessed postinfection LOS or used methods accounting for time to infection using a multistate model or compared propensity score-matched patients with CDI with control patients without CDI. Long-term-care facility studies were excluded. Of the 119 full-text articles, 86 studies (72.3%) met the selection criteria.

Data Extraction and Synthesis:

Two independent reviewers performed the data abstraction and quality assessment. Incidence data were pooled only when the denominators used the same units (eg, patient-days). These data were pooled by summing the number of hospital-onset CDI incident cases and the denominators across studies. Random-effects models were used to obtain pooled mean differences. Heterogeneity was assessed using the I2 value. Data analysis was performed in February 2019.

Main Outcomes and Measures:

Incidence of CDI and CDI-associated hospital LOS in the United States.


When the 13 studies that evaluated incidence data in patient-days due to hospital-onset CDI were pooled, the CDI incidence rate was 8.3 cases per 10 000 patient-days. Among propensity score-matched studies (16 of 20 studies), the CDI-associated mean difference in LOS (in days) between patients with and without CDI varied from 3.0 days (95% CI, 1.44-4.63 days) to 21.6 days (95% CI, 19.29-23.90 days).

Conclusions and Relevance:

Pooled estimates from currently available literature suggest that CDI is associated with a large burden on the health care system. However, these estimates should be interpreted with caution because higher-quality studies should be completed to guide future evaluations of CDI prevention and treatment interventions.

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