Prevalence of Clostridioides difficile infection in Central India: a prospective observational cohort study

Abstract

ntroduction The true burden of Clostridioides difficile infection (CDI) in India remains poorly understood. Prolifigate, unregulated antibiotic use and inappropriate prescribing suggest that CDI could be widespread in India. Our aim was to establish and compare baselines rates of CDI in both in-and outpatient settings in Nagpur city district and rural Melghat, Central India. Methods We recruited adult participants aged ≥18 years of age who could provide written or thumb-print informed consent. A diagnosis of diarrhoea was defined as 3 or more loose stools in a 24-hour period. Immunosuppression was defined as those on prednisolone (>5mg/day), immunomodulators or biologics. Baseline characteristics were also collected and included: demographics, symptomatology, antibiotics exposure, duration of diarrhoea, hospitalisation status at recruitment, and duration, BMI, animal exposure, housing conditions, toilet access, and seasonality. All diarrhoeal samples were tested for CDI using the C. DIFF QUIK CHEK COMPLETE-enzyme immunoassay in accordance with the manufacturers’ instructions. Results C. difficile testing was performed on 1223 patients with acute diarrhoea. A total of 36 patients (2.9%) tested positive for both GDH antigen and toxin expression. A higher% of urban inpatient diarrheal samples tested positive for toxigenic C. difficile (26 cases; 8%) compared to that seen for urban outpatients (9 cases; 3%) and the rural diarrhoeal group (1 outpatient case). Of those testing positive for toxigenic C. difficile, 63.9% were immunosuppressed and almost all (94.4%) were on antibiotics at the time of recruitment. The majority of the toxigenic CDI cases were detected during the monsoon season, lived in very good or good housing conditions, had access to good toilet facilities and reported no co-habitation with animals. Non-toxigenic C. difficile was detected in 6.2%, 4.8%, and 0.5% in the urban inpatient, urban outpatient, and rural populations tested, respectively. Conclusions Toxigenic C. difficile is an important but neglected aetiologic cause of infective diarrhoea in Central India. The higher prevalence within the urban inpatient setting likely reflects greater exposure to antibiotics and hospitalisation. Our findings underscore the need to enhance awareness of and testing of patients with diarrhoea in India, particularly in high-risk individuals with recent or ongoing antibiotic exposure or hospitalisation.