ESBL positivity as an independent predictor of Clostridioides difficile infection: a retrospective cohort study

OBJECTIVES: To evaluate the association between intestinal colonization with multidrug-resistant (MDR) bacteria and the occurrence of Clostridioides difficile infection (CDI). METHODS: We conducted a retrospective cohort study at a tertiary-care infectious diseases department in Prague, Czech Republic, including adults tested for C. difficile between January and December 2024. CDI cases were defined as diarrhoeal patients with positive antigen and toxin by enzyme immunoassay. Controls were symptomatic patients negative for both tests. Stool samples were screened for MDR bacteria, including extended-spectrum beta-lactamase-producing Enterobacterales (ESBL), vancomycin-resistant enterococci (VRE), and carbapenemase-producing organisms. Univariable and multivariable logistic regression analyses identified independent predictors of CDI. RESULTS: Among 192 patients, 100 had CDI and 92 served as controls. ESBL colonization was more frequent in CDI patients (52.0% vs. 23.9%, p<0.001). In multivariable analysis, prior antibiotic exposure (OR 2.67; 95% CI 1.30-5.49; p=0.008) and ESBL colonization (OR 2.86; 95% CI 1.49-5.52; p=0.002) were independently associated with CDI. Previous ICU admission showed borderline significance (OR 2.02; 95% CI 0.95-4.28; p=0.068). VRE was not independently associated, and no carbapenemase-producing organisms were detected. CONCLUSION: ESBL colonization is independently associated with increased odds of CDI and may support risk stratification and antimicrobial stewardship.