CDI Increase During COVID-19 Pandemic Found in Bulgaria

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Older age and use of various medications, including antibiotics, proton pump inhibitors, and corticosteroids were associated with a higher risk of developing C difficile infections.

A research team has identified a number of factors that led to an increase in clostridiodes difficile infections (CDI) during the COVID-19 pandemic in Bulgaria.1

A team, led by Valeri Velev, a University Hospital "Prof. Iv. Kirov”, Medical University of Sofia, compared outcomes of patients who developed CDI prior to the COVID-19 pandemic and during the pandemic in Bulgaria.

The investigators also compared some characteristics of patients with CDI before the onset of the pandemic with patients with CDI during the COVID-19 pandemic.

Antibiotic Use

The overreliance of antibiotics is increasing the risk of antibiotic-resistant disease, which could ultimately lead to CDI, which continues to be a major concern in long-term hospital situations.

In addition, the recent COVID-19 pandemic has led to an increase in antibiotic use and hospital stays.

“CDI is one of the widespread and serious problems directly related to the long-term misuse of antibiotics,” the authors wrote. “The rapid development of the COVID-19 pandemic and the lack of clarity about the pathogenesis of the disease led to heterogeneous empirical approaches to treatment; hence, the multiple hospitalizations, the lack of beds and health personnel led to two significant problems: the inappropriate use of multiple antibiotics in a disease of viral origin and non-compliance with some of the recommendations for limiting nosocomial infections.”

Likely because of the anti-epidemic measures implemented during the pandemic there has been either a slight decrease or increase of CDI in recent years.

In the retrospective cohort study, the investigators examined 246 patients with CDI between March 2021 and August 2021 from 2 tertiary infectious disease hospitals in Bulgaria. The patient population had a mean age of 58 years. The patient group was compared with another group of patients with CDI admitted to the same hospitals between March 2018 and April 2018.

The investigators collected stool samples before and during the COVID-19 period. Each stool sample was tested with a rapid immunochromatographic test for C difficile A/B toxins. The team also tested about 20% of the stool samples for the enzyme and were cultured.

Comparing the Cohorts

The results show there was an increase in patients with CDI during the pandemic. In fact, the rate of patients with CDI increased by 21.95%.

The team also found 73% (n = 38) of CDI diagnosed in the period before the pandemic was first episodes of the disease, compared to 89.8% (n = 221) for the cohort of patients diagnosed during the pandemic.

In addition, the investigators found demographic trends, where patients with CDI associated with COVID-19 were older, had higher rates of neurologic, tumor, and cardiovascular disease, and metabolic syndrome.

There was also higher rates of proton pump inhibitor, antibiotic, and corticosteroid use.

“All these factors lead to the conclusion that increased caution is needed in patients with COVID-19 and that mandatory testing should be done for C. difficile infection at the onset of the diarrheal syndrome,” the authors wrote.


Velev V, Pavlova M, Alexandrova E, et al. Study on patients with clostridioides difficile infection during the COVID-19 pandemic in Bulgaria. Biotechnology & Biotechnological Equipment. 2023;37(1):188-193. doi:10.1080/13102818.2023.2169194