Clostridioides difficile (formerly Clostridium difficile) is a common cause of healthcare-associated infection [[1], [2], [3]]. Patients with C difficile infection (CDI) generally have mild to moderate diarrhea, but severe infections can result in life-threatening dehydration, abdominal distension, hypoalbuminemia with peripheral edema, colitis, and toxic megacolon [1,4]. Disease epidemiology has been extensively documented in Europe and North America [[1], [2], [3]]. In the United States, for instance, the case burden of CDIs was estimated at more than 462,000 cases in 2017, of which approximately 51 % were healthcare-associated infections [5,6]. Among inpatients, CDI can prolong hospitalization by up to 13.6 days and increase medical costs by an average of $21,448 per case (2015 US dollars) [7].

CDI is also associated with high rates of recurrence (compounding the economic burden of the initial infection), with fatality, and with antibiotic resistance. Recurrence has been reported in 7.9 % [8] and 13.5%–35 % [9,10] of all CDI cases in Europe and the United States, respectively. CDI is potentially fatal, with CDI-related deaths estimated to have occurred in approximately 4 % of patients hospitalized with CDI in Europe and in 4%–6% in the United States [5,6,8]. Furthermore, although CDI only accounts for 7.8 % of antibiotic-resistant infections in the United States, more than one-third of antibiotic-resistant deaths are attributed to CDI [5].

C difficile spores are resistant to heat, acid, and many antibiotics, and they can survive in the environment and on food; therefore, spores are regularly ingested [11,12]. CDI occurs when C difficile spores germinate in the colon, leading to production of pathogenic toxins [1].

The dominant risk factor for CDI is recent prior antibiotic use [9]. Individuals at particular risk include the elderly (≥65 years) and those who are immunosuppressed (eg, oncology patients) [[13], [14], [15]]. Other risk factors for CDI beyond recent prior antibiotic, older age, or immunosuppression are multimorbidity, prolonged hospitalization (or multiple hospitalizations), residence in a long-term care facility, and treatment with proton pump inhibitors [9].

Virulence varies across C difficile strains, which are classified by ribotyping, a genotyping method [9,16]. Similar work is based on classification by genotype, which is reported as the sequence type (ST). Consequently, the public health approach to understanding CDI epidemiology is to evaluate C difficile strain distributions [9]. For instance, certain ribotypes (eg, RT027, RT014/020, or RT001/072) have been dominant in Europe and North America, although the balance can change over time and across geographic regions [4,9,17]. Many of these dominant ribotypes are resistant to fluoroquinolones and clindamycin [9].

CDI is also an important cause of disease in Asia [4]. Historically, the reported incidence or prevalence of C difficile in Asian countries has been low relative to Europe and North America [4]. The low reported incidence is likely due to fewer CDI diagnoses that are related, in part, to less frequent testing for CDI because of a lack of clinical awareness of the disease among physicians in Asia [18,19]. Here, we reviewed the extant literature on CDI in Asia to better understand the regional epidemiology and burden, the populations in Asia at highest risk, and the predominant C difficile strains and their antimicrobial resistance patterns.