title: Burden of Clostridium difficile infection in the United States.
abstract: BACKGROUND
  The magnitude and scope of Clostridium difficile infection in the United States continue to evolve.
  
  
  METHODS
  In 2011, we performed active population- and laboratory-based surveillance across 10 geographic areas in the United States to identify cases of C. difficile infection (stool specimens positive for C. difficile on either toxin or molecular assay in residents ≥ 1 year of age). Cases were classified as community-associated or health care-associated. In a sample of cases of C. difficile infection, specimens were cultured and isolates underwent molecular typing. We used regression models to calculate estimates of national incidence and total number of infections, first recurrences, and deaths within 30 days after the diagnosis of C. difficile infection.
  
  
  RESULTS
  A total of 15,461 cases of C. difficile infection were identified in the 10 geographic areas; 65.8% were health care-associated, but only 24.2% had onset during hospitalization. After adjustment for predictors of disease incidence, the estimated number of incident C. difficile infections in the United States was 453,000 (95% confidence interval [CI], 397,100 to 508,500). The incidence was estimated to be higher among females (rate ratio, 1.26; 95% CI, 1.25 to 1.27), whites (rate ratio, 1.72; 95% CI, 1.56 to 2.0), and persons 65 years of age or older (rate ratio, 8.65; 95% CI, 8.16 to 9.31). The estimated number of first recurrences of C. difficile infection was 83,000 (95% CI, 57,000 to 108,900), and the estimated number of deaths was 29,300 (95% CI, 16,500 to 42,100). The North American pulsed-field gel electrophoresis type 1 (NAP1) strain was more prevalent among health care-associated infections than among community-associated infections (30.7% vs. 18.8%, P<0.001).
  
  
  CONCLUSIONS
  C. difficile was responsible for almost half a million infections and was associated with approximately 29,000 deaths in 2011. (Funded by the Centers for Disease Control and Prevention.).
authors.affiliation: The authors' affiliations are listed in the Appendix.
authors.forename: Fernanda C
authors.initials: FC
authors.lastname: Lessa
authors.forename: Yi
authors.initials: Y
authors.lastname: Mu
authors.forename: Wendy M
authors.initials: WM
authors.lastname: Bamberg
authors.forename: Zintars G
authors.initials: ZG
authors.lastname: Beldavs
authors.forename: Ghinwa K
authors.initials: GK
authors.lastname: Dumyati
authors.forename: John R
authors.initials: JR
authors.lastname: Dunn
authors.forename: Monica M
authors.initials: MM
authors.lastname: Farley
authors.forename: Stacy M
authors.initials: SM
authors.lastname: Holzbauer
authors.forename: James I
authors.initials: JI
authors.lastname: Meek
authors.forename: Erin C
authors.initials: EC
authors.lastname: Phipps
authors.forename: Lucy E
authors.initials: LE
authors.lastname: Wilson
authors.forename: Lisa G
authors.initials: LG
authors.lastname: Winston
authors.forename: Jessica A
authors.initials: JA
authors.lastname: Cohen
authors.forename: Brandi M
authors.initials: BM
authors.lastname: Limbago
authors.forename: Scott K
authors.initials: SK
authors.lastname: Fridkin
authors.forename: Dale N
authors.initials: DN
authors.lastname: Gerding
authors.forename: L Clifford
authors.initials: LC
authors.lastname: McDonald
mesh_terms: D000293:Adolescent; D000328:Adult; D017677:Age Distribution; D000368:Aged; D015373:Bacterial Typing Techniques; D002648:Child; D002675:Child, Preschool; D016360:Clostridioides difficile / Q000235:genetics / Q000302:isolation & purification; D003015:Clostridium Infections / Q000453:epidemiology* / Q000401:mortality / Q000635:transmission; D003428:Cross Infection / Q000453:epidemiology; D016521:Electrophoresis, Gel, Pulsed-Field; D005260:Female; D006801:Humans; D015994:Incidence; D007223:Infant; D008297:Male; D008875:Middle Aged; D011159:Population Surveillance; D012008:Recurrence; D017678:Sex Distribution; D014481:United States / Q000453:epidemiology