The rising incidence of Clostridium difficile infection (CDI) could be reduced by lowering exposure to high-risk antibiotics. The objective of this study was to determine the association between antibiotic class and the risk of CDI in the community setting. The EMBASE and PubMed databases were queried without restriction to time period or language. Comparative observational studies and randomized controlled trials (RCTs) considering the impact of exposure to antibiotics on CDI risk among nonhospitalized populations were considered. We estimated pooled odds ratios (OR) for antibiotic classes using random-effect metaanalysis. Our search criteria identified 465 articles, of which 7 met inclusion criteria; all were observational studies. We noted no effect of tetracyclines on CDI risk (OR ‫؍‬ 0.92; 95% CI, 0.61 to 1.40). In the community setting, there is substantial variation in the risk of CDI associated with different antimicrobial classes. Avoidance of high-risk antibiotics (such as clindamycin, CMCs, and fluoroquinolones) in favor of lower-risk antibiotics (such as penicillins, macrolides, and tetracyclines) may help reduce the incidence of CDI.C lostridium difficile, a toxin-producing bacterium that causes diarrhea, is the largest single cause of morbidity and mortality among hospital-acquired infections (1). In hospitals, C. difficile infection (CDI) is generally acquired when patients with predisposing factors such as advanced age and antibiotic use are exposed to C. difficile spores emanating from other hospitalized infected patients (2). With the emergence of increasingly virulent C. difficile strains have come reports of CDIs in patients previously considered to be at low risk of this infection, including those living in the community (3-5). Spore exposure may occur outside inpatient settings, since river water, soil, and foods can be contaminated (6, 7), outpatient exposures to the health care system are common, and transmission may occur within households (8). A recent study noted that the population-based incidence of community-acquired CDI (11.2 cases per 100,000 person-years) was on par with hospital-acquired CDI (12.1 cases per 100,000 personyears) (9).One published meta-analysis and one systematic review have considered the impact of antibiotic exposure on CDI (10, 11) risk among hospital inpatients. The meta-analytic study noted that tetracyclines and penicillins were associated with the lowest risk, while fluoroquinolones, clindamycin, and expanded-spectrum cephalosporins were associated with the highest risk of CDI acquisition, despite considerable confidence interval overlap (10). The systematic review established that the strongest evidence of risk existed for penicillins and clindamycin and that effect estimates for other antibiotic classes were liable to bias (11).In addition to yielding accurate adjusted effect estimates, a systematic review of the association between exposure to antibiotics and community-associated CDI is necessary, since the risk profile is different among nonhospitalized...

ong-term care (LTC) homes have become the epicentre of the coronavirus disease 2019 (COVID-19) pandemic in Canada, with residents of these care homes accounting for more than 80% of the country's deaths. 1-3 Residents of LTC homes are at high risk of contracting severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), owing to their congregate living arrangements and exposure to staff with asymptomatic or presymptomatic SARS-CoV-2 infection. 4-6 These residents are also at high risk of morbidity and mortality from COVID-19, as most are older adults with frailty and multimorbidity. 7 There is widespread concern that despite these predisposing risks, LTC homes were both underprepared and underequipped to protect their residents, and questions have arisen as to whether forprofit LTC homes have had worse COVID-19 outcomes. 8,9 In Ontario, Canada's most populous province, all residents of LTC homes receive personal and nursing care as well as subsidized accommodation under a publicly funded LTC program. Regardless of this governmental funding, individual LTC homes can be owned and operated by for-profit, nonprofit or municipal (public) entities. 10 Several observational studies suggest that for-profit LTC homes tend to deliver inferior care across a variety of outcome and process measures. 11,12 These include lower levels and quality of RESEARCH VULNERABLE POPULATIONS