Clostridioides difficile

What is Clostridioides difficile?

Clostridioides difficile (“C. difficile” or “C. diff”) is a type of spore-forming bacteria that produces two types of toxins.

What are the symptoms?

The main clinical symptoms of C. difficile infection (CDI) are watery diarrhea, fever, nausea, abdominal pain/tenderness, and loss of appetite. More serious conditions can also result such as pseudomembranous colitis (inflammation of the colon), perforations of the colon, and sepsis.

What is C. diff colonization?

It is possible to carry C. diff bacteria in your body but not show any symptoms; this is called colonization. After treatment, repeat testing is not recommended if the patient’s symptoms have resolved, since many patients remain colonized with the bacteria.

Who is at risk?

Some patients/residents may be at higher risk for developing C. diff due to prolonged use of antibiotics, underlying gastrointestinal issues or prior gastrointestinal surgery, history of frequent hospitalizations, immunocompromised status, advanced age, or other underlying chronic health conditions. It is important that both the patient and the healthcare providers take the appropriate steps to help prevent an infection.


Infection Prevention

To prevent CDI, doctors, nurses, and other healthcare providers should follow CDC infection prevention guidelines including:

  • Use antibiotics judiciously.
  • Implement contact precautions for patients/residents with known or suspected CDI:
    • Place patients/residents with CDI in private rooms.  If private rooms are not available, patients/residents can be placed in rooms (cohorted) with other persons with CDI.
    • Use gloves when entering the room of a patient/resident with CDI and during patient/resident care.
    • Perform hand hygiene after removing gloves.
      • Because alcohol does not kill C. difficile spores, use of soap and water is more efficacious than alcohol-based hand rubs. However, early experimental data suggest that, even using soap and water, the removal of C. difficile spores is more challenging than the removal or inactivation of other common pathogens.
      • Preventing contamination of the hands via glove use remains the cornerstone for preventing C. difficile transmission via the hands of healthcare workers.
      • If your institution experiences an outbreak, consider using only soap and water for hand hygiene when caring for patients/residents with CDI.
    • Use gowns when entering the room of a patient/resident with CDI and during patient/resident care.
    • Use dedicated medical equipment or perform cleaning and disinfection of any shared medical equipment.
    • Continue these precautions until diarrhea ceases.
      • Because patients/residents with CDI continue to shed the bacteria for a number of days after diarrhea stops, some facilities routinely continue isolation for either several days beyond symptom resolution or until discharge, depending upon the type of setting and average length of stay.
  • Implement an environmental cleaning and disinfection strategy:
    • Ensure adequate cleaning and disinfection of environmental surfaces and reusable devices, especially items likely to be contaminated with feces and surfaces that are touched frequently.
    • Consider using an Environmental Protection Agency (EPA)-registered disinfectant with a sporicidal claim for environmental surface disinfection after cleaning in accordance with label instructions. Generic sources of hypochlorite (e.g., household chlorine bleach) also may be appropriately diluted and used.
      • Note: Standard EPA-registered hospital disinfectants are not effective against Clostridioides difficile spores.
      • Hypochlorite-based disinfectants may be most effective in preventing C. difficile transmission in units with high endemic rates of C. difficile infection.

Clinical Practice Guidelines for Clostridioides  difficile Infection in Adults:  2010 Update by the Society for Healthcare Epidemiology of America (SHEA) and the Infectious Diseases Society of America (IDSA)
Clostridioides difficile Infection in Adults and Children (2013) – a policy statement from the American Academy of Pediatrics
SHEA/IDSA Compendium of Strategies to Prevent Healthcare-Associated Infections in Acute Care Hospitals – C. difficile
CDC CDI Prevention Collaborative Toolkit – contains background on epidemiology of CDI as well as core and supplemental prevention strategies.


Reporting Requirements

To prevent CDI, doctors, nurses, and other healthcare providers should follow CDC infection prevention guidelines including:

  • Use antibiotics judiciously.
  • Implement contact precautions for patients/residents with known or suspected CDI:
    • Place patients/residents with CDI in private rooms.  If private rooms are not available, patients/residents can be placed in rooms (cohorted) with other persons with CDI.
    • Use gloves when entering the room of a patient/resident with CDI and during patient/resident care.
    • Perform hand hygiene after removing gloves.
      • Because alcohol does not kill C. difficile spores, use of soap and water is more efficacious than alcohol-based hand rubs. However, early experimental data suggest that, even using soap and water, the removal of C. difficile spores is more challenging than the removal or inactivation of other common pathogens.
      • Preventing contamination of the hands via glove use remains the cornerstone for preventing C. difficile transmission via the hands of healthcare workers.
      • If your institution experiences an outbreak, consider using only soap and water for hand hygiene when caring for patients/residents with CDI.
    • Use gowns when entering the room of a patient/resident with CDI and during patient/resident care.
    • Use dedicated medical equipment or perform cleaning and disinfection of any shared medical equipment.
    • Continue these precautions until diarrhea ceases.
      • Because patients/residents with CDI continue to shed the bacteria for a number of days after diarrhea stops, some facilities routinely continue isolation for either several days beyond symptom resolution or until discharge, depending upon the type of setting and average length of stay.
  • Implement an environmental cleaning and disinfection strategy:
    • Ensure adequate cleaning and disinfection of environmental surfaces and reusable devices, especially items likely to be contaminated with feces and surfaces that are touched frequently.
    • Consider using an Environmental Protection Agency (EPA)-registered disinfectant with a sporicidal claim for environmental surface disinfection after cleaning in accordance with label instructions. Generic sources of hypochlorite (e.g., household chlorine bleach) also may be appropriately diluted and used.
      • Note: Standard EPA-registered hospital disinfectants are not effective against Clostridioides difficile spores.
      • Hypochlorite-based disinfectants may be most effective in preventing C. difficile transmission in units with high endemic rates of C. difficile infection.

Clinical Practice Guidelines for Clostridioides  difficile Infection in Adults: 2010 Update by the Society for Healthcare Epidemiology of America (SHEA) and the Infectious Diseases Society of America (IDSA)
Clostridioides difficile Infection in Adults and Children (2013) – a policy statement from the American Academy of Pediatrics
SHEA/IDSA Compendium of Strategies to Prevent Healthcare-Associated Infections in Acute Care Hospitals – C. difficile
CDC CDI Prevention Collaborative Toolkit – contains background on epidemiology of CDI as well as core and supplemental prevention strategies.


Impact in the United States

  • Morbidity
    • In a recent national prevalence survey, Clostridioides difficile was the most commonly reported pathogen, causing 12% of HAIs, and an estimated 80,400 hospital-onset infections (citation).
    • According to the latest CDC National and State HAI Progress Report, in 2014, acute care hospitals experienced an 8% reduction in hospital-onset C. difficile infections compared to 2011.
      • Virginia hospitals experienced a 2% reduction in hospital-onset C. difficile infections between 2011 and 2013.
    • C. difficile accounts for 15-25% of all episodes of antibiotic-associated diarrhea.
    • In Virginia, hospitalizations for C. difficile increased from 9 per 100,000 people in 2000 to 29 per 100,000 people in 2010. (citation)  In 2010 in Virginia:
      • The rate of hospitalization with C. difficile was more than twice as high for people 85 years or older than for people 65 to 84 years of age.
      • Compared to men, C. difficile hospitalization rates were 30% higher for women.
    • In 2009, patients diagnosed with C. difficile in Virginia hospitals stayed an average of 13.2 days, almost three times as long as the average stay of all other patients (4.6 days). (citation)
  • Mortality
    • CDI has been associated with an attributable mortality rate of 6.9% at 30 days after diagnosis and 16.7% at 1 year. (citation)
  • Costs
    • Nationally, the estimated cost per infection ranges from $6,000 – $9,000 and the estimated total cost per year ranges from $1 billion – $1.6 billion. (citation)
    • In 2009 in Virginia, the total hospital cost for patients with C. difficile was over $157 million. The average hospital cost for patients with C. difficile was nearly three times higher than patients without C. difficile ($23,190 vs. $8,860). (citation)

Resources

Advancing Excellence in America’s Nursing Homes – checklists for nursing homes to help improve C. diff prevention policies, procedures, knowledge and practices. Includes assessment checklists for early identification/containment, hand hygiene, cleaning/disinfection, and antibiotic stewardship.
AHA/HRET Hospital Engagement Network 2.0 – change package, improvement strategies, checklist, and other resources
Antimicrobial stewardship webpage
APIC Guide to Preventing Clostridioides difficile Infections, 2013
CDC Commentary: Testing for Clostridioides difficile Infection (Medscape login required; registration free)
CDC Vital Signs Report: Making Health Care Safer – Reducing Clostridioides difficile Infection (March 2012) – latest findings of progress on C. difficile prevention in different healthcare settings
Morbidity and Mortality Weekly Report (MMWR) – March 6, 2012 – more detailed information on methodology of Vital Signs report
C. difficile fact sheet for assisted living facilities and nursing homes
Clostridioides difficile in Long-Term–Care Facilities for the Elderly, 2002 (SHEA Position Paper)
Clostridioides difficile Prevention – educational flyer for consumers that contains C. difficile facts and prevention strategies. Developed by VDH and VHI.
Deadly Diarrhea (CDC infographic)
Drug Resistance and Antibiotic Stewardship fact sheet
General C. difficile fact sheet
NHSN Multidrug-resistant Organism and Clostridioides difficile Infection (MDRO/CDI) Module – click on the appropriate healthcare setting and select the MDRO/CDI link to access the training, protocols, forms, analysis resources, and other support materials
SHEA Patient Education Guide (C. diff) – fact sheet that educates patients and their families about 7 types of HAIs (including C. diff) and how to work with healthcare professionals to prevent them.
Vermont Department of Health C. diff Patient Education Guide
VHQC/VDH Clostridioides difficile infection prevention collaborative

  • Conducted in partnership with VHQC
  • Statewide project with enrolled acute care and long-term care facilities to conduct surveillance for C. difficile lab ID events, implement prevention strategies, and share best practices
  • Collaborative resources available by contacting the VDH HAI Program

For more patient resources, please see the Infection Prevention page or go to the CDC C. difficile website.