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Distinguishing Clostridium difficile Recurrence From Reinfection: Independent Validation of Current Recommendations

Published online by Cambridge University Press:  08 June 2017

Ana Durovic
Division of Infectious Diseases and Hospital Epidemiology, University Hospital Basel, Basel, Switzerland
Andreas F. Widmer
Division of Infectious Diseases and Hospital Epidemiology, University Hospital Basel, Basel, Switzerland
Reno Frei
Division of Clinical Microbiology, University Hospital Basel, Basel, Switzerland
Sarah Tschudin-Sutter*
Division of Infectious Diseases and Hospital Epidemiology, University Hospital Basel, Basel, Switzerland
Address correspondence to Sarah Tschudin-Sutter, MD, MSc, Division of Infectious Diseases and Hospital Epidemiology, University Hospital Basel, Petersgraben 4, CH-4031 Basel, Switzerland (



Distinguishing recurrent Clostridium difficile infection (CDI), defined as CDI caused by the same genotype, from reinfection with a different genotype, has important implications for surveillance and clinical trials investigating treatment effectiveness. We validated the proposed 8-week period for distinguishing “same genotype CDI” from “different genotype CDI,” and we aimed to identify clinical variables with distinctiveness to propose an improved definition.


From January 2004 to December 2013, a cohort of all inpatients with CDI at the University Hospital Basel, Switzerland, was established, and respective strains were collected. In patients with a second episode of CDI, both strains were compared using polymerase chain reaction (PCR) ribotyping. The standard definition of recurrence (within 8 weeks after initial diagnosis) was evaluated for its performance to predict CDI caused by the same genotype.


Among 750 patients with CDI, 130 (17.3%) were diagnosed with recurrence or reinfection. Strains from both episodes were available from 106 patients. Identical strains were identified in 36 patients with recurrence (36 of 47) and 27 patients with reinfection (27 of 59). Sensitivity, specificity, and negative and positive predictive values of the standard definition were 56%, 74%, 53%, and 76%, respectively. An extended period of 20 weeks resulted in the best match for both sensitivity and specificity (83% and 58%, respectively), while none of the clinical characteristics revealed independent distinctive power.


Our results challenge the utility of the 8-week cutoff for distinguishing recurrent CDI from reinfection. An extended period of 20 weeks may result in improved overall performance characteristics, but this finding requires external validation.

Infect Control Hosp Epidemiol 2017;38:891–896

Original Articles
© 2017 by The Society for Healthcare Epidemiology of America. All rights reserved 

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PREVIOUS PRESENTATION. A summary of this article was presented orally at the 26th ECCMID European Congress of Clinical Microbiology and Infectious Diseases in Amsterdam, Netherlands, on April 11, 2016.



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