Clostridioides difficile colonization amplification despite limited in-hospital transmission: A modeling study

BACKGROUND: Although healthcare-associated transmission of Clostridioides difficile is a recognized public health concern, community-onset infections represent an important component of the overall disease burden. This paradox likely reflects the underappreciated interplay between these settings. We aimed to quantify in-hospital transmission and the hospital's contribution to community colonization by estimating the intrinsic reproduction number (Ri) and introducing the colonization amplification index (Ai), defined as the ratio of colonized patients at discharge to those at admission. Given the potential contribution of external cases, we also evaluated interventions targeting asymptomatic carriers at admission to reduce disease burden. METHODS AND FINDINGS: We developed a compartmental model informed by data from UCSF Medical Center to capture C. difficile transmission dynamics among symptomatic and asymptomatic patients. Across simulations, the median Ri was 0.61 (Q1-Q3: 0.53, 0.71), consistently indicating limited sustained in-hospital transmission (Ri < 1). In contrast, Ai was 1.9 (Q1-Q3: 1.7, 2.1), suggesting substantial amplification of colonization during hospital stay. Amplification of colonization persisted in sensitivity analyses, with Ri exceeding 1 under boundary values of low colonization prevalence at admission, a low proportion of colonized patients progressing to symptomatic disease, and prolonged incubation periods. Redefining healthcare-associated C. difficile infection (CDI) using thresholds from ≥1-day post-admission instead of the standard threshold of >3 days post-admission increased Ai and Ri by 11% and 21%, respectively. A threshold of ≥5 days post-admission reduced these metrics by 5% and 8%, respectively. Interventions targeting asymptomatic carriers through contact precautions and/or prophylactic treatment reduced both Ai and CDI incidence, with combined interventions yielding the greatest reductions, followed by contact precautions alone. Our main limitation stems from uncertainty in some parameters describing the disease's natural history, particularly colonization prevalence at admission, progression to symptomatic disease, and the incubation period, which may affect the precision of our estimates despite sensitivity analyses. CONCLUSIONS: Our findings indicate that in most potential scenarios, in-hospital transmission of C. difficile is limited (Ri < 1) and likely sustained by continuous importation of cases from the community. Nevertheless, hospitalization amplifies colonization (Ai > 1), which potentially contributes to community transmission. These results underscore the importance of interventions addressing asymptomatic carriers, a currently overlooked source of spread. Our study highlights the need to broaden metrics beyond Ri to capture hospitals' contribution to the C. difficile burden. Future infection control strategies should address colonization dynamics at admission and potentially at discharge to mitigate transmission and reduce the overall burden of C. difficile.