{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,30]],"date-time":"2026-09-30T13:58:32Z","timestamp":1790776712118,"version":"4.1.0"},"reference-count":38,"publisher":"Oxford University Press (OUP)","issue":"10","license":[{"start":{"date-parts":[[2026,9,21]],"date-time":"2026-09-21T00:00:00Z","timestamp":1789948800000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"name":"Duke Clinical and Translational Science Institute"},{"DOI":"10.13039\/100005568","name":"North Carolina Water Resources Research Institute","doi-asserted-by":"publisher","id":[{"id":"10.13039\/100005568","id-type":"DOI","asserted-by":"publisher"}]}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":[],"published-print":{"date-parts":[[2026,9,29]]},"abstract":"<jats:title>Abstract<\/jats:title>\n                  <jats:sec>\n                    <jats:title>Background<\/jats:title>\n                    <jats:p>Geospatial surveys have identified livestock operations as potential sources for community-acquired Clostridioides difficile infection. Confirmatory studies integrating individual-level risk factors, geospatial data, and environmental surveys are limited.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p>We conducted 2 parallel studies: (1) a case-control assessment of C difficile risk associated with livestock and (2) a microbiologic survey of surface waters and wastewater influent for C difficile. For aim 1, adult residents of North Carolina tested for C difficile through the Duke University Health System from March 2020 to December 2025 were included. Tests sent after day 3 of hospitalization (presumed hospital-onset) were excluded. Multivariable logistic regression with generalized estimating equations was used to assess C difficile risk associated with livestock operations while adjusting for age, comorbidities, antibiotic receipt, and hospital contact. For aim 2, samples collected from 3 surface water and 2 municipal wastewater sites in North Carolina from April 2022 to October 2023 were tested for C difficile gene targets by quantitative polymerase chain reaction.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>The case-control cohort included 26 195 tests from 21 045 unique subjects, 3835 (14.6%) of which were positive for C difficile by nucleic acid amplification testing. Residence in the same watershed as commercial swine operations was associated with C difficile risk (adjusted odds ratio, 1.11 [95% confidence interval, 1.00\u20131.23]; P = .04). While C difficile gene targets were ubiquitous in municipal wastewater, they were not detected in 3 regional surface waters.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusions<\/jats:title>\n                    <jats:p>Swine operations were associated with C difficile risk even after adjustment for individual-level risk factors. Clostridioides difficile detection in water varies by source.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1093\/ofid\/ofag598","type":"journal-article","created":{"date-parts":[[2026,9,17]],"date-time":"2026-09-17T19:13:37Z","timestamp":1789672417000},"source":"Crossref","is-referenced-by-count":0,"title":["Reexamining Novel Risk Factors for Community-Acquired\n                    <i>Clostridioides difficile<\/i>\n                    : A Multimodal Approach"],"prefix":"10.1093","volume":"13","author":[{"ORCID":"https:\/\/orcid.org\/0000-0003-0650-4894","authenticated-orcid":false,"given":"Nicholas A","family":"Turner","sequence":"first","affiliation":[{"name":"Division of Infectious Diseases, Duke University Medical Center , Durham, North Carolina ,","place":["USA"]},{"name":"Duke Center for Antimicrobial Stewardship and Infection Prevention , Duke University, Durham, North Carolina ,","place":["USA"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Angela","family":"Harris","sequence":"additional","affiliation":[{"name":"Department of Civil, Construction, and Environmental Engineering, NC State University , Raleigh, North Carolina ,","place":["USA"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0000-6646-800X","authenticated-orcid":false,"given":"Benjamin J","family":"Clark","sequence":"additional","affiliation":[{"name":"Department of Civil, Construction, and Environmental Engineering, NC State University , Raleigh, North Carolina ,","place":["USA"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-7238-0300","authenticated-orcid":false,"given":"Bobby G","family":"Warren","sequence":"additional","affiliation":[{"name":"Duke Center for Antimicrobial Stewardship and Infection Prevention , Duke University, Durham, North Carolina ,","place":["USA"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Aaron","family":"Barrett","sequence":"additional","affiliation":[{"name":"Duke Center for Antimicrobial Stewardship and Infection Prevention , Duke University, Durham, North Carolina ,","place":["USA"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0007-5439-9570","authenticated-orcid":false,"given":"Judith","family":"Kays","sequence":"additional","affiliation":[{"name":"Department of Civil, Construction, and Environmental Engineering, NC State University , Raleigh, North Carolina ,","place":["USA"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-6882-5496","authenticated-orcid":false,"given":"Deverick J","family":"Anderson","sequence":"additional","affiliation":[{"name":"Division of Infectious Diseases, Duke University Medical Center , Durham, North Carolina ,","place":["USA"]},{"name":"Duke Center for Antimicrobial Stewardship and Infection Prevention , Duke University, Durham, North Carolina ,","place":["USA"]}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"286","published-online":{"date-parts":[[2026,9,21]]},"reference":[{"key":"2026093009165275800_ofag598-B1","doi-asserted-by":"crossref","first-page":"1320","DOI":"10.1056\/NEJMoa1910215","article-title":"Trends in U.S. burden of Clostridioides difficile infection and outcomes","volume":"382","author":"Guh","year":"2020","journal-title":"N Engl J Med"},{"key":"2026093009165275800_ofag598-B2","doi-asserted-by":"crossref","first-page":"e1914149","DOI":"10.1001\/jamanetworkopen.2019.14149","article-title":"Epidemiologic trends in Clostridioides difficile infections in a regional community hospital network","volume":"2","author":"Turner","year":"2019","journal-title":"JAMA Netw 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