Clostridium difficile colitis

Clostridium difficile colitis is an infection of the large intestine caused by bacteria that produce harmful toxins, often occurring after taking antibiotics. This common healthcare infection can range from mild diarrhea to life-threatening complications.

Table of contents

• What is Clostridium difficile colitis?
• Names and identification
• Affected body part
• What causes this infection?
• How the infection spreads
• Who is at risk?
• Symptoms of infection
• Possible complications
• How is it diagnosed?
• Treatment options
• Infection returning
• How to prevent spreading the infection

What is Clostridium difficile colitis?

Clostridioides difficile (also known as Clostridium difficile and often called C. difficile or C. diff) is a type of bacteria that can cause swelling and irritation of the large intestine, or colon. This inflammation, known as colitis, can cause diarrhea, fever, and abdominal cramps^[1][2].

The bacterium is often called C. difficile or C. diff. Illness from C. difficile often occurs after using antibiotic medicines. It mostly affects older adults in hospitals or in long-term care settings. People not in care settings or hospitals also can get C. difficile infection. Some strains of the bacterium that can cause serious infections are more likely to affect younger people^[1].

C. difficile is estimated to cause almost half a million infections in the United States each year. In the U.S., 500,000 infections cause 15,000 deaths each year^[2][3].

Names and identification

Clostridioides difficile colitis, Clostridium difficile colitis, C. diff colitis, C. difficile infection, CDI, Pseudomembranous colitis, Antibiotic-associated colitis

The bacterium used to be called Clostridium difficile, and the newer name is Clostridioides difficile. Both names refer to the same organism^[1][2].

Affected body part

• Colon (large intestine)
• Intestinal lining

Clostridioides difficile is a bacterium that causes an infection of the colon, the longest part of the large intestine^[1]. C. difficile releases toxins that damage the cells in your intestinal lining. This causes inflammation in your intestinal lining and colon (colitis)^[3].

What causes this infection?

C. difficile colitis results from a disturbance of the normal bacterial flora of the colon, colonization by C. difficile, and the release of toxins that cause mucosal inflammation and damage^[4].

The large intestine has many good bacteria that keep it healthy and do not cause disease. If you take antibiotics to kill bacteria that do cause disease, your medicine may also kill the good bacteria. This may allow Clostridioides difficile (C. diff) bacteria to grow in your large intestine. They can release harmful substances called toxins^[5].

A healthy immune system normally protects your gut from C. diff infection by keeping C. diff levels under control. If they grow out of control, it’s because something has affected the balance between helpful bacteria and unhelpful bacteria. Everyone has bacteria in their intestines. Helpful types of living bacteria help to keep other bacteria, like C. diff, in check^[3].

Antibiotic exposure is the primary risk factor for C. difficile colitis. The most commonly implicated agents include the cephalosporins, fluoroquinolones, clindamycin, and penicillins^[4]. Almost any antibiotic can cause this disorder, but clindamycin, penicillins (such as ampicillin and amoxicillin), cephalosporins (such as ceftriaxone), and fluoroquinolones (such as levofloxacin and ciprofloxacin) are implicated most often^[8].

People who take medicines that reduce stomach acid, such as proton pump inhibitors, also have a greater risk of getting a C. diff infection^[5].

How the infection spreads

C. diff germs spread from person to person in poop, but the bacteria are often found in the environment. Finding C. diff germs in the home is not unusual, even when no one in the home has been ill with C. diff infection^[2].

When C. diff germs are outside the body, they become spores. These spores are an inactive form of the germ and have a protective coating allowing them to live for months or years on surfaces and in the soil. The germs become active again when you swallow these spores and they reach the intestines^[2].

C. difficile reproduces by releasing spores. These spores can also spread on skin, surfaces and other items. This means if you touch something with the spores on it, and then eat or touch your mouth, you can get C. diff that way^[3].

Outside your body, C. diff turns into spores that are very hard to kill, both inside and outside of your intestines. They’re resistant to heat, acid and many antibiotics and disinfectants^[3].

Who is at risk?

While C. diff infection can affect anyone, most cases occur when you’ve been taking antibiotics or soon after you’ve finished taking antibiotics. People are up to 10 times more likely to get C. diff infection while taking an antibiotic or during the three months after, with longer courses potentially doubling their risk^[2].

Other risk factors include^[2]:

• Older age (65 or older)
• Recent stay at a hospital or nursing home
• A weakened immune system, such as organ transplant patients taking immunosuppressive drugs or people with HIV/AIDS or cancer
• Previous infection with C. diff or known exposure to the germs

C. diff infection is more common among patients in healthcare settings, such as hospitals and nursing homes. This is because many people carrying C. diff stay or get treated in those facilities^[2].

You can still get C. diff infection even if you have none of these risk factors^[2].

Symptoms of infection

Symptoms often begin within 5 to 10 days after starting an antibiotic. But symptoms can occur as soon as the first day or up to three months later^[1].

The most common symptom, and usually the first to appear, is watery diarrhea. A mild infection will cause diarrhea at least three times a day, often with some abdominal cramping^[3].

The most common symptoms of mild to moderate C. difficile infection are^[1]:

• Watery diarrhea three or more times a day for more than one day
• Mild belly cramping and tenderness

As C. diff infection becomes more severe, diarrhea increases. It may occur as much as 10 to 15 times a day. You may notice traces of blood in your poop or other symptoms, like^[3]:

• Persistent abdominal pain
• Swollen, distended abdomen
• Nausea and vomiting
• Loss of appetite
• Fever
• Rapid heart rate

People who have a severe C. difficile infection tend to lose too much bodily fluid, a condition called dehydration. They might need to be treated in a hospital for dehydration^[1].

C. diff diarrhea is typically mushy or porridge-like, but not completely liquid. Sometimes, it has a green tint, though other bacterial infections can also cause this. Occasionally, it contains blood, mucus or pus^[3].

Many people notice a distinctive odor with C. diff diarrhea. They describe it as unusually strong and oddly sweet. This smell may be because C. diff increases the levels of bile acids in your poop^[3].

Possible complications

Common complications include^[2]:

• Dehydration
• Inflammation of the colon, known as colitis

Rare complications include^[2]:

• Serious intestinal condition, such as toxic megacolon
• Sepsis, the body’s extreme response to an infection
• Death

C. difficile infection can cause the colon to become inflamed. It sometimes can form patches of raw tissue that can bleed or make pus^[1]. These patches of yellow and white tissue on the inside of the colon are called pseudomembranes^[4].

How is it diagnosed?

Your doctor may think you have Clostridioides difficile (C. diff) colitis if both of the following are true: You are taking, or you recently took, antibiotics, and you have symptoms of the illness^[5].

A diagnosis of C. difficile infection is based on having diarrhea, other symptoms of C. difficile infection, and C. difficile in a stool sample. People who have regular, formed stools should not be tested for C. difficile infection^[10].

To confirm the diagnosis, a sample of your stool will be tested. The test will check for the bacteria by looking for its DNA. Another test may be done to look for the toxins that C. diff produces^[5].

A two-step algorithm should be used to guide diagnostic testing: enzyme immunoassay for glutamate dehydrogenase and toxins A and B, followed by nucleic acid amplification testing if initial results are indeterminate. For patients likely to have C. difficile infection based on clinical symptoms, either nucleic acid amplification testing or the two-step algorithm is appropriate^[13].

Your doctor may look at the inside of your colon through a thin, lighted tube called a colonoscope. In the most serious cases, the doctor may see patches of yellow and white tissue on the inside of the colon^[5].

An X-ray of the stomach area or a CT scan can look for possible complications of C. difficile infection. These imaging tests can detect thickened colon wall, enlarged bowel, or a hole in the lining of the colon^[10].

Treatment options

If possible, your doctor will have you stop taking the antibiotic that caused the infection. Your doctor may then treat Clostridioides difficile (C. diff) colitis with an antibiotic other than the one that caused the infection^[5].

Oral vancomycin and fidaxomicin are preferred over metronidazole for initial episodes of C. difficile infection^[13]. Fidaxomicin is now recommended as first-line treatment due to a lower risk of CDI recurrence^[4].

If you have severe diarrhea, you also may be given fluids to prevent dehydration and to make sure you have the right amount of minerals (electrolytes) in your blood. Or you will be given medicine to control diarrhea^[5].

In patients with severe, complicated, or fulminant CDI (hypotension, shock, ileus or megacolon), oral (or via nasogastric tube) vancomycin 500 mg every 6 hours along with intravenous (IV) metronidazole is recommended. Rectal vancomycin may also be added in patients with ileus^[11].

If C. diff is severe or comes back a few times, a fecal transplant may be done. This treatment places stool from a donor into the colon of a person who has C. diff infection. The good bacteria in the donor stool help heal the colon^[5].

Fecal microbiota transplantation is recommended for patients with multiple recurrences of C. difficile infection in whom appropriate antibiotic therapy has been ineffective^[13]. Fecal microbiota transplantation is a reasonable treatment option with high cure rates in patients who have had multiple recurrent episodes and have received appropriate antibiotic therapy for at least three of the episodes^[13].

In rare cases, if you have very severe pain or serious complications, you may need surgery to remove the diseased part of your colon^[9]. Patients with fulminant colitis and toxic megacolon may require operative intervention, such as colectomy with preservation of the rectum^[11].

Carry on taking antibiotics prescribed for C. diff until you’ve finished all your tablets, capsules or liquid, even if you feel better. If you stop your treatment early, your symptoms could come back^[7].

Infection returning

About 1 in 6 people who have had a C. diff infection will get it again within the following 2 to 8 weeks^[9]. About 1 in 9 people who get C. diff infection will get it again in the subsequent 2-8 weeks^[17].

Approximately 20% of individuals who are hospitalized become colonized with C. difficile during hospitalization, and more than 30% of these patients develop diarrhea^[4]. Once infected with C. difficile, the rate of disease recurrence is 20-40% when using metronidazole and vancomycin antibiotics as first-line therapy^[4].

C. diff infection can come back. If you start to have diarrhea after you have finished your antibiotic treatment, talk to your doctor right away^[23].

The best way to be sure you don’t get C. diff infection again is to work with a healthcare professional to avoid taking unnecessary antibiotics. Tell any healthcare professionals (including primary care provider, dentist’s office and others) if you’ve had a C. diff infection. This important information will help them make the best decisions when prescribing antibiotics in the future^[17].

How to prevent spreading the infection

C. diff infections can spread very easily. There are steps you can take to reduce the risk of passing it on to others^[7]:

• Stay at home until at least 48 hours after your diarrhea stops
• Wash your hands regularly using soap and water
• Clean the toilet and area around it with disinfectant after each use
• Wash clothes and sheets with poo on separately from other washing at the highest possible temperature

Do not share towels and flannels. Do not take medicine to stop diarrhea like loperamide (Imodium) because it can prevent the infection being cleared from your body. Do not use hand sanitizer as this does not kill or remove C. diff^[7].

Keep your hands clean by washing them well and often with soap and clean, running water. This is most important after you use the toilet and before you make and eat food^[23].

In routine or endemic settings, hands should be cleaned with either soap and water or an alcohol-based product, but during outbreaks soap and water is superior^[13].

After the diarrhea is better, you are much less likely to spread C. diff. But you still need to take extra care to keep your home clean. Clean bathroom surfaces with a bleach solution to kill any C. diff spores. To dilute household bleach, follow the directions on the label^[23].

Any time antibiotics are used, they can cause side effects, including C. diff infection. Take antibiotics only when you need them^[2]. Antibiotic stewardship reduces rates of C. difficile infection^[13].

You should return to work or school only when your symptoms have stopped^[17].