Increased Community-Associated <i>Clostridioides difficile</i> Infections in Quebec, Canada, 2008–20151

C lostridioides difficile infections (CDIs) are com- monly acquired in healthcare settings (1).In 2003, an outbreak of CDI in the province of Quebec, Canada (population, 8.2 million), required implementation of mitigation strategies and prompted introduction of a surveillance program (2,3).Afterward, incidence of healthcare-associated CDIs (HA-CDIs) in the province decreased from 13.7 cases/10,000 patient-days in 2004-2005 to 6.9/10,000 patient-days in 2014-2015.Although CDIs afflict mainly hospitalized patients, recent studies report increased incidence of community-associated CDIs (CA-CDIs) (4-6).Whereas most of the focus in North America has been on HA-CDI, we describe and compare long-term trends in incidence rates for HA-CDI and CA-CDI in Quebec. The StudyTo evaluate HA-CDI and CA-CDI trends in Quebec, we performed a quasi-experimental study.We used prospectively collected data from the Quebec Health Ministry C. difficile Infection Surveillance Program (SPIN-CD), a mandatory surveillance program introduced in 2004 (7).As of 2018, all 90 acute-care hospitals with >1,000 admissions annually participate in SPIN-CD.These hospitals, which represent 97% of all admissions in the province, use a centralized web portal to report HA-CDI incidence density, computed as the aggregate number of cases divided by the aggregate number of patient-days per 4-week period.CA-CDI incidence rates are expressed as the number of CA-CDIs/100,000 population as reported by the Quebec Institute of Statistics (8).CDI is defined as diarrhea (>3 unformed stools in <24 hours with symptoms lasting >24 hours) with no other etiology and either a positive toxigenic C. difficile test result or evidence of pseudomembranes during histopathologic or colonoscopic examination (9).A case is considered to be HA-CDI if symptoms appear >72 hours after admission or <4 weeks after discharge.A CA-CDI case is defined as illness in a hospitalized patient for whom symptoms developed within 72 hours of admission and who had not been hospitalized or received ambulatory care in the previous 4 weeks.Nonhospitalized CA-CDI case-patients and recurrences (i.e., new CDI episodes within 8 weeks of a previous episode) are not reportable to SPIN-CD.Definitions did not change during the study period.The type of laboratory assay used to detect C. difficile was at the discretion of each center (10).To focus the analysis on the postepidemic period (April 2008-March 2015), we excluded data from the epidemic period (August 2004-March 2008). We used Poisson regression models on time series Increased Community-Associated Clostridioides difficile Infections in

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