Impact of the COVID-19 pandemic on the incidence of Clostridioides difficile infection based on hospital surveillance data: a systematic review and meta-analysis

BACKGROUND: Clostridioides difficile infection (CDI) remains a substantial burden on healthcare systems worldwide. The COVID-19 pandemic has had profound and multifaceted effects on healthcare delivery and infection control practices, potentially influencing the epidemiology of CDI. OBJECTIVE: To assess whether the coronavirus disease 2019 (COVID-19) pandemic has influenced the incidence of CDI and to explore potential contributing factors. METHODS: This systematic review and meta-analysis was conducted in accordance with the PRISMA guidelines. Seven databases were searched for relevant literature published from December 2019 to October 2025. Study quality was assessed via the Newcastle‒Ottawa Scale (NOS) and the Joanna Briggs Institute (JBI) critical appraisal tools. Random- or fixed-effects models were selected according to heterogeneity. Publication bias was evaluated via funnel plots and Egger's test, and sensitivity analyses were conducted. The primary outcome was the incidence rate of CDI, expressed as cases per 10,000 patient-days. Incidence rate ratios (IRR) were calculated to compare the incidence of CDI between the prepandemic and pandemic periods. RESULTS: Sixteen studies were included. The pooled CDI incidence rate was 4.42 (95% CI: 3.37-5.46) per 10,000 patient-days in the prepandemic period and 3.80 (95% CI: 2.63-4.96) per 10,000 patient-days during the pandemic. The pooled incidence rate ratio was 0.80 (95% CI: 0.67-0.97), indicating a significant reduction in the incidence of CDI. This decline was associated with changes in medical practices (e.g., the suspension of nonurgent and high-risk procedures), antimicrobial stewardship practices, and strengthened infection control measures (e.g., enhanced hand hygiene and environmental disinfection) during the pandemic. CONCLUSION: Compared with the prepandemic period, the incidence of CDI decreased significantly during the COVID-19 pandemic. This finding suggests that strengthened infection prevention measures, improved antimicrobial stewardship, and adaptations in healthcare delivery may have contributed to reduced CDI transmission. Reinforcing these evidence-based foundational strategies may help mitigate ‌the risk of CDI and other healthcare-associated infections during future public health emergencies.