Clostridium difficile infections - Facts and surveillance



Clostridium difficile is an anaerobic bacterium, widely distributed in soil and the intestinal tracts of animals. The clinical spectrum of C. difficile infection (CDI) ranges from mild diarrhoea to severe life threatening pseudomembranous colitis. CDI is generally, but not always associated with previous use of antibiotics. The transmission of C. difficile can be patient-to-patient, via contaminated hands of healthcare workers or by environmental contamination. There is an increase of reports of community-acquired CDI in individuals previously not recognised as predisposed.

The burden of healthcare-associated CDIs in acute care hospitals in the EU/EEA was estimated at 123 997 cases annually [1]. In the ECDC point prevalence survey (PPS) of healthcare-associated infections (HAIs) and antimicrobial use in European acute care hospitals 2011-2012 (ECDC PPS), C. difficile was the 8th most frequently detected microorganism among HAIs. Using a conservative figure of 3% attributable mortality, the number of deaths occurring as the direct consequence of healthcare-associated CDI can be estimated at 3 700 per year in the EU/EEA.

Hospital-based surveillance of CDIs in EU/EEA Member States, using a common European protocol, was launched on 1 January 2016. The protocol enables hospitals and Member States to collect comparable data to guide their practices to prevent and control CDIs. By 31 March 2016, hospitals in at least 20 of the 31 EU/EEA Member States had conducted surveillance using the protocol.

The ECDC directory of online resources for prevention and control of antimicrobial resistance and HAIs contains guidance for prevention and control of CDI published by ECDC, EU/EEA Member States, international and national agencies and professional societies.


The objectives of European surveillance of CDIs are:

  • To estimate the incidence of CDIs in European acute care hospitals;
  • Toassess the burden of CDIs (including that of recurrent CDI cases) in European acute care hospitals;
  • To provide participating hospitals with a standardised protocol to measure and compare their own CDI incidence rates with those reported by other participating hospitals;
  • To assess the adverse outcomes of CDIs including death;
  • To describe the epidemiology of C. difficile at the local, national and European level, including antibiotic susceptibility, PCR ribotype, presence of Clostridium difficile toxin A (TcdA), Clostridium difficile toxin B (TcdB) and binary toxin, morbidity and mortality of CDI, and the detection of new/emerging PCR ribotypes.



The European protocol for CDI surveillance prescribes the methodology and provides the data collection tools required to achieve the objectives of European surveillance of CDIs. This requires national or regional coordinators to choose between the three CDI surveillance options for data collection by data collectors at the hospital level. Each option corresponds to the collection of progressively more detailed information:  

  • the ‘minimal’ CDI surveillance option corresponds to the collection of only agregated numerator and denominator data; 
  • the ‘light’ surveillance option necessitates the collection of case-based numerator data and aggregate denominator data;
  • the ‘enhanced’ surveillance option necessitates the collection of microbiological data, i.e. molecular characterisation and
  • antimicrobial susceptibility testing data, for the isolates corresponding to the first 10 consecutively detected CDI cases in each hospital.


 HelicsWin.Net is a free software application developed by ECDC for the manual entry of data from surveillance of HAIs including CDI. Data are stored on the user’s computer until the user chooses to export the data from the software application.


2006 ECDC publishes case definitions for CDI together with the ESCMID Study Group for Clostridium difficile ( ESGCD) [2]​
2007 ​ECDC launches the European C. difficile survey (ECDIS, 2008-2009) [3, 4, 5]
​2008 ​ECDC and the European C. difficile-Infection Control Group publish a consensus regarding infection control measures to limit spread of C. difficile [6]
2010 to 2014

The ECDC-funded project ‘Supporting capacity building for surveillance of Clostridium difficile infections at European level’ (ECDIS-Net) develops, together with EU/EEA Member States and ECDC experts, a standardised protocol for CDI surveillance which was successfully pilot tested in 14 EU/EEA Member States in 2013 (Eurosurveillance, 2016).  

The ECDIS-Net project also pilot tested materials to ensure laboratory diagnostic capacity including a training curriculum, standard operating procedures, a set of C. difficile reference strains and a PCR ribotyping nomenclature reference database. In both 2011 and 2014, the project assessed the current CDI diagnostic and typing capacity of EU/EEA Member States, identifying progress in the use of recommended diagnostic algorithms and typing method (Eurosurveillance, 2016).

​2015 The ECDC Burden of Communicable Diseases in Europe (BCoDE) project estimates that healthcare-associated CDIs were responsible for 31 disability-adjusted life years (DALYs) per 100,000 population in 2011-2012 in the EU/EEA (article in press)   ECDC publishes a European protocol for hospital-based surveillance of CDI, based on the protocol that was pilot tested during the ECDIS-Net project.   ECDC publishes an online directory of guidance for prevention and control of CDI.
2016 ​​Start of European hospital-based surveillance of CDI.



  1. European Surveillance of Clostridium difficile infections. Surveillance protocol version 2.2. European Centre for Disease Prevention and Control. Stockholm: ECDC; 2015. DOI: doi 10.2900/44795

  2. Antibiotic resistance in Europe: the challenges ahead. ECDC Antimicrobial Resistance and Healthcare-Associated Infections Programme. Euro Surveill. 2009;14(45):pii=19405.

  3. Clostridium difficile: summary of actions in the European Union. Suetens C.  Euro Surveill. 2008;13(31):pii=18944.

  4. Survey of Clostridium difficile infection surveillance systems in Europe, 2011. Kola A, Wiuff C, Akerlund T, van Benthem BH, Coignard B, Lyytikäinen O, Weitzel-Kage D, Suetens C, Wilcox MH, Kuijper EJ, Gastmeier P, on behalf of members of ECDIS-Net. Euro Surveill. 2016;21(29):pii=30291. DOI:

  5. Standardised surveillance of Clostridium difficile infection in European acute care hospitals: a pilot study, 2013. van Dorp SM, Kinross P, Gastmeier P, Behnke M, Kola A, Delmée M, Pavelkovich A, Mentula S, Barbut F, Hajdu A, Ingebretsen A, Pituch H, Macovei IS, Jovanović M, Wiuff C, Schmid D, Olsen KE, Wilcox MH, Suetens C, Kuijper EJ, for the European Clostridium difficile Infection Surveillance Network (ECDIS-Net) on behalf of all participants. Euro Surveill. 2016;21(29):pii=30293. DOI:

  6. Survey of diagnostic and typing capacity for Clostridium difficile infection in Europe, 2011 and 2014. van Dorp SM, Notermans DW, Alblas J, Gastmeier P, Mentula S, Nagy E, Spigaglia P, Ivanova K, Fitzpatrick F, Barbut F, Morris T, Wilcox MH, Kinross P, Suetens C, Kuijper EJ, for the European Clostridium difficile Infection Surveillance Network (ECDIS-Net) project on behalf of all participants. Euro Surveill. 2016;21(29):pii=30292. DOI:

  7. Editorial: Difficile indeed. Tassios PT. Euro Surveill. 2016;21(29):pii=30290. DOI: