Surveillance Open Access
Like 0



is a leading cause of healthcare-associated diarrhoea in middle and high-income countries. Up to 2018, there has been no systematic, annual surveillance for infections (CDI) in France.


To provide an updated overview of the epidemiology of CDI in France between 2010 and 2017 based on five different data sources.


This is a descriptive study of retrospective surveillance and alerts data. Incidence of CDI cases was estimated through the CDI incidence survey (2016) and data from the French National Uniform Hospital Discharge Database (PMSI; 2010–16). Testing frequency for CDI was estimated through the CDI incidence survey and point prevalence studies on healthcare-associated infections (HAI; 2012 and 2017). The national early warning response system for HAI (HAI-EWRS, 2012–17) and National Reference Laboratory data (2012–17) were used to follow the number of severe CDI cases and/or outbreaks.


In 2016, CDI incidence in acute care was 3.6 cases per 10,000 patient days (PD). There was a statistically significant increase in CDI incidence between 2010 and 2016 (+ 14% annually) and testing frequency was 47.4 per 10,000 PD. The number of CDI HAI-EWRS notifications decreased between 2015 and 2017 with only a few large outbreaks reported.


The CDI incidence estimate increased from 2010, but remained below the European average of 7 per 10,000 PD in 2014; there were fewer severe cases or clusters reported in France. The consistency between PMSI and laboratory-based estimated CDI incidence could allow for more routine monitoring of CDI incidence.


Article metrics loading...

Loading full text...

Full text loading...



  1. Czepiel J, Dróżdż M, Pituch H, Kuijper EJ, Perucki W, Mielimonka A, et al. Clostridium difficile infection: review. Eur J Clin Microbiol Infect Dis. 2019;38(7):1211-21.  https://doi.org/10.1007/s10096-019-03539-6  PMID: 30945014 
  2. Hensgens MP, Goorhuis A, Dekkers OM, Kuijper EJ. Time interval of increased risk for Clostridium difficile infection after exposure to antibiotics. J Antimicrob Chemother. 2012;67(3):742-8.  https://doi.org/10.1093/jac/dkr508  PMID: 22146873 
  3. Gabriel L, Beriot-Mathiot A. Hospitalization stay and costs attributable to Clostridium difficile infection: a critical review. J Hosp Infect. 2014;88(1):12-21.  https://doi.org/10.1016/j.jhin.2014.04.011  PMID: 24996516 
  4. Barbut F, Bouée S, Longepierre L, Goldberg M, Bensoussan C, Levy-Bachelot L. Excess mortality between 2007 and 2014 among patients with Clostridium difficile infection: a French health insurance database analysis. J Hosp Infect. 2018;98(1):21-8.  https://doi.org/10.1016/j.jhin.2017.07.006  PMID: 28712548 
  5. Leffler DA, Lamont JT. Clostridium difficile Infection. N Engl J Med. 2015;373(3):287-8. PMID: 26176396 
  6. Coignard B, Barbut F, Blanckaert K, Thiolet JM, Poujol I, Carbonne A, et al. Emergence of Clostridium difficile toxinotype III, PCR-ribotype 027-associated disease, France, 2006. Euro Surveill. 2006;11(9):E060914.1. PMID: 17075146 
  7. O’Connor JR, Johnson S, Gerding DN. Clostridium difficile infection caused by the epidemic BI/NAP1/027 strain. Gastroenterology. 2009;136(6):1913-24.  https://doi.org/10.1053/j.gastro.2009.02.073  PMID: 19457419 
  8. Pépin J, Valiquette L, Alary ME, Villemure P, Pelletier A, Forget K, et al. Clostridium difficile-associated diarrhea in a region of Quebec from 1991 to 2003: a changing pattern of disease severity. CMAJ. 2004;171(5):466-72.  https://doi.org/10.1503/cmaj.1041104  PMID: 15337727 
  9. Kuijper EJ, Coignard B, Tüll PESCMID Study Group for Clostridium difficileEU Member StatesEuropean Centre for Disease Prevention and Control. Emergence of Clostridium difficile-associated disease in North America and Europe. Clin Microbiol Infect. 2006;12(6) Suppl 6;2-18.  https://doi.org/10.1111/j.1469-0691.2006.01580.x  PMID: 16965399 
  10. Deaths involving Clostridium difficile: England and Wales, 1999-2004. Health Stat Q. 2006; (30):56-60. PMID: 16759080 
  11. Smith A. Outbreak of Clostridium difficile infection in an English hospital linked to hypertoxin-producing strains in Canada and the US. Euro Surveill. 2005;10(6):E050630.2. PMID: 16783109 
  12. Eckert C, Coignard B, Hebert M, Tarnaud C, Tessier C, Lemire A, et al. ICD-Raisin Working Group. Clinical and microbiological features of Clostridium difficile infections in France: the ICD-RAISIN 2009 national survey. Med Mal Infect. 2013;43(2):67-74.  https://doi.org/10.1016/j.medmal.2013.01.004  PMID: 23498135 
  13. Davies KA, Longshaw CM, Davis GL, Bouza E, Barbut F, Barna Z, et al. Underdiagnosis of Clostridium difficile across Europe: the European, multicentre, prospective, biannual, point-prevalence study of Clostridium difficile infection in hospitalised patients with diarrhoea (EUCLID). Lancet Infect Dis. 2014;14(12):1208-19.  https://doi.org/10.1016/S1473-3099(14)70991-0  PMID: 25455988 
  14. Thiolet JM PI, Vaux S, Alleaume S, Coignard B. The French healthcare-associated infection early warning and response system: a tool for detecting and monitoring emerging infectious diseases in healthcare facilities. Bulletin épidémiologique hebdomadaire.2011;15-16-17:5
  15. Santé publique France. Raisin. Réseau de surveillance des bactéries multirésistantes à partir des laboratoires de microbiologie BMR-Raisin - Guide méthodologique pour l’année 2016 [Monitoring Multidrug-Resistant Bacteria from Microbiology Laboratories: the BMR-Raisin netwok - Methodological Guide for 2016]. Paris: Santé publique France; [accessed 30 Jul 2019]. French. Available from: https://www.santepubliquefrance.fr/content/download/56390/file/bmr-raisin-protocole-2016.pdf
  16. European Centre for Disease Prevention and Control (ECDC). European Surveillance of Clostridium difficile infections. Surveillance protocol version 2.3. Stockholm: ECDC; 2017.Available from: https://ecdc.europa.eu/en/publications-data/european-surveillance-clostridium-difficile-infections-surveillance-protocol-1
  17. Crobach MJ, Planche T, Eckert C, Barbut F, Terveer EM, Dekkers OM, et al. European Society of Clinical Microbiology and Infectious Diseases: update of the diagnostic guidance document for Clostridium difficile infection. Clin Microbiol Infect. 2016;22(Suppl 4):S63-81.  https://doi.org/10.1016/j.cmi.2016.03.010  PMID: 27460910 
  18. Ministére des Solidarités et de la Santé. Panoramas de la DRESS : les établissements de santé, édition 2018 [Panoramas of the DRESS: health facilities, 2018 edition]. Paris: Ministére des Solidarités et de la Santé; 2018. French. Available from: https://drees.solidarites-sante.gouv.fr/etudes-et-statistiques/publications/panoramas-de-la-drees/article/les-etablissements-de-sante-edition-2018.html
  19. Thiolet JM, Vaux S, Lamy M, Gauthier A, Barret AS, Leon L, et al. Enquête nationale de prévalence des infections nososcomiales et des traitements anti-infectieux en établissements de santé, France, mai-juin 2012 [Point prevalence survey of healthcare-associated infections and antimicrobial use in French hospitals, May-June 2012 - Results]. 2013. French. Available from: https://www.santepubliquefrance.fr/maladies-et-traumatismes/infections-associees-aux-soins-et-resistance-aux-antibiotiques/infections-associees-aux-soins/documents/rapport-synthese/enquete-nationale-de-prevalence-des-infections-nosocomiales-et-des-traitements-anti-infectieux-en-etablissements-de-sante-france-mai-juin-2012.-r
  20. Boudemaghe T, Belhadj I. Data Resource Profile: The French National Uniform Hospital Discharge Data Set Database (PMSI). Int J Epidemiol. 2017;46(2):392-392d.  https://doi.org/10.1093/ije/dyw359  PMID: 28168290 
  21. World health Organization (WHO). International statistical classification of diseases and related health problems - 10th revision. Geneva: WHO; [accessed 30 Jul 2019]. Available from: https://www.who.int/classifications/icd/ICD10Volume2_en_2010.pdf
  22. Securite Sociale l’Assurance Maladie. Classification commune des actes médicaux.[Cited 30 Jul 2019]. French. Available from: https://www.ameli.fr/accueil-de-la-ccam/index.php
  23. Barbut F, Day N, Bouée S, Youssouf A, Grandvoinnet L, Lalande V, et al. Toxigenic Clostridium difficile carriage in general practice: results of a laboratory-based cohort study. Clin Microbiol Infect. 2019;25(5):588-94.  https://doi.org/10.1016/j.cmi.2018.12.024  PMID: 30616013 
  24. Jones G, Taright N, Boelle PY, Marty J, Lalande V, Eckert C, et al. Accuracy of ICD-10 codes for surveillance of Clostridium difficile infections, France. Emerg Infect Dis. 2012;18(6):979-81.  https://doi.org/10.3201/eid1806.111188  PMID: 22607707 
  25. Djuretic T, Wall PG, Brazier JS. Clostridium difficile: an update on its epidemiology and role in hospital outbreaks in England and Wales. J Hosp Infect. 1999;41(3):213-8.  https://doi.org/10.1016/S0195-6701(99)90018-X  PMID: 10204123 
  26. Institut national de la statistique et des etudes economiques (INSEE). Nathalie Blanpain et Guillemette Buisson. Population projections to 2070: twice as many people aged 75 and over as in 2013. INSEE premiere. 2016; n°1619. Abstract. Insee: Paris: 2016. Available from: https://www.insee.fr/en/statistiques/2581288
  27. Luk S, Ho AYM, Chan EHY, Tsang IHL, Ng TK, To WK, et al. High Prevalence and Frequent Acquisition of Clostridium difficile Ribotype 002 Among Nursing Home Residents in Hong Kong. Infect Control Hosp Epidemiol. 2018;39(7):782-7.  https://doi.org/10.1017/ice.2018.92  PMID: 29733004 
  28. Ratnayake L, McEwen J, Henderson N, Nathwani D, Phillips G, Brown D, et al. Control of an outbreak of diarrhoea in a vascular surgery unit caused by a high-level clindamycin-resistant Clostridium difficile PCR ribotype 106. J Hosp Infect. 2011;79(3):242-7.  https://doi.org/10.1016/j.jhin.2011.06.013  PMID: 21864938 
  29. van Dorp SM, Kinross P, Gastmeier P, Behnke M, Kola A, Delmée M, et al. European Clostridium difficile Infection Surveillance Network (ECDIS-Net) on behalf of all participants. Standardised surveillance of Clostridium difficile infection in European acute care hospitals: a pilot study, 2013. Euro Surveill. 2016;21(29):30293.  https://doi.org/10.2807/1560-7917.ES.2016.21.29.30293  PMID: 27472820 
  30. Haut conseil de la santé publique. Avis relatif à la maîtrise de la diffusion des infections à Clostridium difficile dans les établissements de santé français [Opinion on the control of the spread of Clostridium difficile infections in French health establishments]. Paris: Haut conseil de la santé publique; [Accessed 30 Jul 2019]. French. Available from: https://www.hcsp.fr/Explore.cgi/avisrapportsdomaine?clefr=32
  31. Tschudin-Sutter S, Kuijper EJ, Durovic A, Vehreschild M, Barbut F, Eckert C, et al. Guidance document for prevention of Clostridium difficile infection in acute healthcare settings. Clin microbial infect. 2018;24(10):1051-1054.
  32. Hensgens MP, Goorhuis A, Dekkers OM, van Benthem BH, Kuijper EJ. All-cause and disease-specific mortality in hospitalized patients with Clostridium difficile infection: a multicenter cohort study. Clin Infect Dis. 2013;56(8):1108-16.  https://doi.org/10.1093/cid/cis1209  PMID: 23300235 
  33. Cassini A, Plachouras D, Eckmanns T, Abu Sin M, Blank HP, Ducomble T, et al. Burden of Six Healthcare-Associated Infections on European Population Health: Estimating Incidence-Based Disability-Adjusted Life Years through a Population Prevalence-Based Modelling Study. PLoS Med. 2016;13(10):e1002150.  https://doi.org/10.1371/journal.pmed.1002150  PMID: 27755545 
  34. European Centre for Disease Prevention and Control (ECDC). Healthcare associated infections: Clostridium difficile infections. ECDC. Annual epidemiological report for 2016. Stockholm, ECDC; 2018. Available from: https://ecdc.europa.eu/en/publications-data/healthcare-associated-infections-clostridium-difficile-infections-annual

Data & Media loading...

Submit comment
Comment moderation successfully completed
This is a required field
Please enter a valid email address
Approval was a Success
Invalid data
An Error Occurred
Approval was partially successful, following selected items could not be processed due to error