A potentially life-threatening gut infection is rising across every region of England, with new analysis revealing significant geographical differences in reported rates.
Analysis of UK Health Security Agency (UKHSA) surveillance data by TrialMed examined annual resident-area C. difficile infection rates across all seven NHS England regions between 2020 and 2021 and 2024 and 2025, using rates per 100,000 residents.
The North West recorded both the highest overall rate and the fastest rise, increasing by 18.1 cases per 100,000 residents from 28.4 in 2020 and 2021–46.5 in 2024 and 2025. By comparison, London recorded the lowest rate, rising from 15.0–18.8 per 100,000 over the same period.
Dr Viljoen, clinical research physician at TrialMed, said the regional differences suggest C. diff is becoming a wider public health issue rather than remaining confined to hospitals.
“Many people still think of C. diff as a hospital infection, but the data shows the picture is far more complex than that,” Dr Viljoen said. “Cases are increasing across every NHS England region, which could be for a number of reasons. Regional differences do not necessarily mean infection prevention is better or worse in one area compared to another. They are more likely to reflect a combination of demographics, antibiotic prescribing patterns, population health, healthcare usage, and the number of higher-risk patients living within those communities.”
Regional rates in 2024 and 2025
In 2024 and 2025, reported resident-area infection rates per 100,000 residents across the regions were
- North West. 46.5 cases per 100,000 residents.
- South West. 37.6 cases per 100,000 residents.
- Midlands. 36.6 cases per 100,000 residents.
- North East & Yorkshire. 34.1 cases per 100,000 residents.
- East of England. 33.1 cases per 100,000 residents.
- South East. 29.4 cases per 100,000 residents.
- London. 18.8 cases per 100,000 residents.
When examining the full five-year period, the North West also maintained the highest average reported resident-area infection rate.
Dr Viljoen said the geographical differences may reflect a range of demographic and health factors.
“C. diff disproportionately affects older adults, people who frequently receive antibiotics, and individuals with underlying health conditions,” Dr Viljoen explained. “Regions with larger populations of higher-risk patients may naturally report higher infection rates. Socioeconomic factors can also influence risk indirectly. People with greater healthcare needs are more likely to receive repeated antibiotic treatment, spend more time in healthcare settings, and develop the underlying conditions associated with severe infection.”
The role of antibiotics in C. diff infections
C. diff is a bacterium that can live harmlessly within the gut. Problems can begin when antibiotics disrupt the normal balance of bacteria in the digestive system, allowing C. diff to multiply rapidly and produce toxins that damage the bowel lining. Symptoms include watery diarrhoea, fever, nausea, abdominal pain, and loss of appetite. In serious cases, it can cause severe inflammation of the colon and life-threatening complications.
Dr Viljoen emphasised that recent antibiotic use remains the single largest risk factor regardless of location. “Antibiotics are one of medicine’s most important tools, but every course also alters the microbiome to some degree,” Dr Viljoen said. “When protective bacteria are removed, it creates an opportunity for organisms such as C. diff to gain a foothold. That is why good antibiotic stewardship remains such an important part of preventing infections. The goal is not to avoid antibiotics completely, but to ensure they are used when clinically necessary and in the most appropriate way possible.”
Majority of cases classified as community-onset
The analysis also evaluated where cases were classified as beginning, finding that community-onset infections accounted for the majority of reported cases across all seven NHS England regions. The South West recorded the highest community-onset share at 62.1%, followed by the South East at 60.4%, while London recorded the lowest proportion at just over half of reported cases.
However, community-onset classification describes when an infection was identified rather than where it was contracted. Recent healthcare exposure was recorded in 41.8%–52.5% of community-onset cases across the regions, peaking in the North East and Yorkshire at 52.5%, followed by the North West at 50.8% and the Midlands at 50.2%.
“People tend to associate C. diff exclusively with hospitals, but most reported cases in this analysis were classified as community-onset,” Dr Viljoen stated. “That should be a reminder that awareness of symptoms matters outside healthcare settings too. Community-onset does not necessarily mean somebody acquired the infection within the community. Many patients classified in this way still have recent healthcare exposure, antibiotic treatment, or other recognised risk factors.”
Warning signs and advice
According to Dr Viljoen, key symptoms to monitor include
Persistent watery diarrhoea
“Frequent watery diarrhoea is one of the most common signs of C. diff infection and should not be ignored, particularly after recent antibiotic use.”
Fever alongside digestive symptoms
“The combination of diarrhoea and fever warrants greater attention because it can indicate an active infection rather than a simple stomach upset.”
Significant abdominal pain
“C. diff toxins trigger inflammation within the bowel, which can result in cramping, tenderness, and worsening abdominal discomfort.”
Symptoms after antibiotics
“Recent antibiotic treatment remains the most important warning sign. If diarrhoea develops during a course of antibiotics or shortly afterwards, people should seek medical advice rather than assuming it is merely a side effect.”
Dr Viljoen outlined key precautions for the public. “The key message from this analysis is that C. diff is affecting every region of England, and reported rates have increased throughout the country during the past five years,” Dr Viljoen advised. “Understanding the symptoms, using antibiotics appropriately, and seeking advice when symptoms develop after antibiotic treatment remain some of the most effective ways people can protect themselves.”