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

OBJECTIVE 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. METHODS 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. RESULTS 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. CONCLUSIONS 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.