Clostridium difficile infection

Clostridioides difficile is a bacterium that can cause diarrhea and serious inflammation of the colon, particularly affecting people who have recently taken antibiotics or are in healthcare settings.

Table of contents

• What is Clostridioides difficile?
• Symptoms
• How the infection spreads
• Who is at risk?
• Diagnosis
• Treatment
• Complications
• Prevention
• Recurrence and recovery

What is Clostridioides difficile?

Clostridioides difficile (pronounced klos-TRID-e-OY-dees dif-uh-SEEL) is a bacterium that causes an infection of the colon, which is the longest part of the large intestine. The bacterium is often called C. difficile or C. diff. It was formerly known as Clostridium difficile^[1][2].

C. diff is a spore-forming, toxin-producing bacterium. This means it can exist in two forms: a dormant spore that has a tough protective coating allowing it to survive for months or years on surfaces, and an active form that results when the spore reaches your intestines and begins to grow^[6].

The bacterium is commonly found in the environment, including in soil, air, and water. It is present in small amounts in the bodies of about 1 to 3% of the U.S. population without causing any harm. However, when conditions allow it to multiply out of control, it releases toxins that damage the cells in your intestinal lining, causing symptoms ranging from mild diarrhea to life-threatening damage to the colon^[4][9].

Clostridium difficile, C. difficile, C. diff

• Colon (large intestine)
• Intestines

Symptoms

Symptoms often begin within 5 to 10 days after starting an antibiotic, but they 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. Whether you have symptoms, and how severe they are, depends on the extent of the damage from the toxins produced by C. diff^[4].

Mild to moderate infection

The most common symptoms of mild to moderate C. diff infection include^[1][2]:

• Watery diarrhea three or more times a day for more than one day
• Mild belly cramping and tenderness
• Fever
• Stomach tenderness or pain
• Loss of appetite
• Nausea

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. Many people notice a distinctive odor with C. diff diarrhea that they describe as unusually strong and oddly sweet^[4].

Severe infection

People who have a severe C. diff infection tend to lose too much bodily fluid, a condition called dehydration. They might need to be treated in a hospital. The infection can cause the colon to become inflamed, and it sometimes can form patches of raw tissue that can bleed or make pus^[1].

Symptoms of severe infection include^[1][4]:

• Watery diarrhea as often as 10 to 15 times a day
• Belly cramping and pain, which may be severe
• Fast or rapid heart rate
• Persistent abdominal pain
• Swollen, distended abdomen
• Nausea and vomiting
• Fever
• Loss of fluids (dehydration)

C. diff symptoms may resemble food poisoning or stomach flu at first. If you’re taking antibiotics, it’s possible to mistake C. diff diarrhea for a normal side effect of medication^[4].

How the infection spreads

A healthy immune system normally protects your gut from C. diff infection by keeping the bacterium under control. Everyone has bacteria in their intestines, and helpful types of bacteria help to keep other bacteria, like C. diff, in check^[4].

The most common cause of C. diff infection is taking antibiotics. Using them upsets the balance between helpful and unhelpful bacteria in your gut microbiome (the community of good and bad germs that live in your body), allowing C. diff to dominate and overgrow. The effect of antibiotics can last as long as several months. If you come in contact with C. diff germs during this time, you can get sick^[2][4].

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. Healthy people don’t get infected often even if the spores reach their intestines. If your immune system is weak or you’ve recently taken antibiotics, you could get sick^[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. 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^[4].

C. diff bacteria can live on people’s skin. People who touch an infected person’s skin can pick up the germs on their hands. If they don’t wash their hands, they can spread the germs to people and things they touch^[18].

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][8]:

• 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
• Taking a proton pump inhibitor (PPI), such as omeprazole, or other medicines that reduce stomach acid

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

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. Although traditionally considered a primary healthcare-associated infection, C. diff is also increasingly diagnosed within community settings^[2][3].

C. diff 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][4].

Diagnosis

A diagnosis of C. diff infection is based on having diarrhea, other symptoms of C. diff infection, and C. diff in a stool sample^[10].

If C. diff infection is suspected, one or more tests of a stool sample can show either the toxins or strains of the bacteria that produce toxins. People who have regular, formed stools should not be tested for C. diff infection. Some people carry the bacteria but aren’t sick and don’t get treated^[10].

If you have been taking antibiotics recently and have symptoms of a C. diff infection, you should see your health care provider. Your provider will ask about your symptoms and do a lab test of your stool^[8].

In some cases, you might also need imaging tests. Rarely, to help confirm a diagnosis of C. diff infection, a health care provider might check the inside of the colon. Tests used are either flexible sigmoidoscopy or colonoscopy. The tests involve putting a flexible tube with a small camera on one end into the colon to look for problem areas. These tests also can look for other causes of the symptoms^[10].

An X-ray of the stomach area or a CT scan can look for possible complications of C. diff infection, such as a thickened colon wall, enlarged bowel, or a hole (perforation) in the lining of the colon^[10].

Treatment

Treatments are used only for symptoms of infection. People who carry the bacteria but aren’t sick don’t get treated^[10].

Stopping or changing antibiotics

If C. diff infection is related to an antibiotic, a health care provider will likely stop its use. Often, however, an antibiotic is needed to treat another infectious condition. A switch to a different antibiotic may be needed in these cases^[10].

Antibiotics for C. diff

Certain antibiotics can treat C. diff infections. The decision to treat C. diff infection and the type of therapy administered depend on the severity of infection. The ISDA/SHEA 2021 updated guideline for C. diff treatment recommends administering fidaxomicin for initial and recurrent infections, with oral vancomycin as an alternative^[11][14].

Fidaxomicin is a macrocyclic lactone antibiotic that inhibits RNA polymerase, therefore preventing transcription. It is bactericidal against C. diff and demonstrates only moderate inhibitory activity against other bacteria. It was reported to be superior to oral vancomycin in reducing recurrent C. diff infections^[15].

Your symptoms should improve a few days after starting the new course of antibiotics. But it may be 1 to 2 weeks before the infection clears up completely. It’s important to 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^[5].

In patients with severe, complicated, or fulminant (extremely serious) C. diff (hypotension, shock, ileus, or megacolon), oral vancomycin along with intravenous (IV) metronidazole is recommended. Rectal vancomycin may also be added in patients with ileus^[11].

Other treatments

The infection can sometimes be treated at home, or you might need to go into hospital. This is because C. diff infections can sometimes lead to more serious problems^[5].

You’ll also be given advice about how to avoid dehydration, such as making sure you drink plenty of water^[5].

If you have a severe case, you may need to stay in the hospital. If you have very severe pain or serious complications, you may need surgery to remove the diseased part of your colon. Patients with fulminant colitis and toxic megacolon may require operative intervention, such as colectomy with preservation of the rectum^[8][11].

Fecal microbiota transplantation

About 1 in 6 people who get a C. diff infection will get it again within 2 to 8 weeks. If the C. diff infection comes back 2 or more times, you may be offered a fecal microbiota transplant (FMT). This is where bacteria from a healthy person’s poop is put into your gut to help stop the infection. FMT uses stool (or bacteria from stool) from a healthy donor to try to restore the balance of healthy bacteria in your intestines^[5][8].

Complications

C. diff can cause illness ranging from mild diarrhea to life-threatening complications. Common complications include^[2]:

• Dehydration (loss of too much bodily fluid)
• Inflammation of the colon, known as colitis

Rare but serious complications include^[2][3]:

• Serious intestinal conditions, such as toxic megacolon (a rare but life-threatening complication where the colon becomes severely enlarged)
• Pseudomembranous colitis (when yellowish white plaques form on the intestinal mucosa)
• Sepsis (the body’s extreme response to an infection)
• Death

In severe cases, C. diff infection can cause the colon to become inflamed and sometimes form patches of raw tissue that can bleed or make pus^[1].

Prevention

There are several steps you can take to prevent getting or spreading C. diff^[2][18]:

Handwashing

Washing your hands with soap and water is the best way to prevent the spread of C. diff from person to person. Wash your hands with soap and water every time you use the bathroom and before you eat. Remind relatives and friends taking care of you to do the same^[18].

Do not use hand sanitizer, as this does not kill or remove C. diff. Only cleaners such as bleach can kill the spores. Thoroughly washing your hands with soap and water can remove spores from hands^[5][9].

Personal hygiene

Take showers and wash with soap to remove any C. diff germs you could have on your body. Taking a shower with soap and water can reduce the C. diff on your skin and lessen the chance of it spreading^[18].

At home

If you have C. diff infection or are caring for someone with C. diff infection^[18]:

• Stay at home until at least 48 hours after your diarrhea stops
• Try to use a separate bathroom if you have diarrhea from C. diff infection. If you can’t, be sure the commonly touched surfaces in the bathroom are cleaned before others use it
• Clean the toilet and area around it with disinfectant after each use
• 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

Cleaning surfaces and laundry

Cleaning and disinfecting surfaces and laundry, especially if someone is sick in your home already, can reduce your risk of C. diff infection. Hospitals use special cleaning products to kill C. diff. You can also use one of these products at home. Be sure to follow manufacturer instructions. Those instructions often include cleaning first, such as with soap and water, and then using one of the recommended disinfectants^[18].

Focus on regularly cleaning items that you touch with your hands, including doorknobs, electronics, refrigerator handles, toilet flushers, and toilet seats^[18].

Wash bed linens, towels, household linens, and clothing (especially underwear) in the hottest water that is safe for items. Use chlorine bleach if you can safely do so without damaging items. Consider wearing gloves while handling items. Always wash hands with soap and water after handling laundry, even if you wore gloves^[18].

In healthcare settings

Make sure all healthcare professionals clean their hands before and after caring for you. Ask them to clean their hands if you don’t see them do so. While caring for you and other patients with C. diff infection, healthcare professionals will use certain precautions like wearing a gown and gloves. This will prevent the spread of C. diff to themselves and other patients^[18].

Antibiotic stewardship

Any time antibiotics are used, they can cause side effects, including C. diff infection. Take antibiotics only when you need them. Talk to a healthcare professional about the best treatment for your illness and your risk for developing C. diff^[2][18].

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^[16].

Recurrence and recovery

About 1 in 6 to 1 in 9 people who have had a C. diff infection will get it again in the subsequent 2 to 8 weeks. This is called recurrent C. diff. It could be that your original infection came back or that you have a new infection. The risk of a subsequent infection increases with each new C. diff infection^[6][8][16].

Go back to see the health care provider if your symptoms get worse, you feel very unwell after starting the antibiotics, or your symptoms come back afterwards. Contact your provider if your symptoms come back. If your symptoms return, or you become very unwell, treatment may need to be repeated or you may need treatment in hospital^[5][10].

When to resume everyday life

You should return to work or school only when your symptoms have stopped. You should only resume everyday life (return to work or school) after symptoms stop^[16].

After treatment

The risk of spreading C. diff after completing treatment is low. But if you’re carrying the germ, even without symptoms, you can still spread it to others and should follow prevention measures^[16].

After treatment, you should not be tested again to make sure you’re cured, because once you recover from your C. diff infection, you could still be carrying the germs. A test would only show the germs are still there, but not whether you’re likely to become sick again^[16].