Clostridium Difficile Infection
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Basics
Description
- A gram-positive, spore-forming anaerobic bacillus that releases toxins to produce clinical disease
- Infection caused by Clostridium difficile is frequently associated with antibiotic use, hospitalization, residence at long-term care facilities, and age.
- Severity of infection can range from diarrhea to pancolitis, perforation, and death.
- System(s) affected: gastrointestinal
- Synonyms(s): C. difficile–associated disease or diarrhea (CDAD); C. difficile infection; C. difficile colitis; C. diff
Epidemiology
Incidence- C. difficile is a common hospital-acquired infection. The incidence is rising (1).
- There are ~15 new cases per 1,000 clinical discharges; higher with increased age (2)
- Rates of complications are also increasing (1).
Prevalence
- C. difficile causes ~25% of all cases of antibiotic-associated diarrhea.
- Prevalence of community-acquired C. difficile infection is increasing. Up to 40% of patients require hospitalization (2).
- C. difficile is a commensurate organism in 2–5% of the adult U.S. population.
Etiology and Pathophysiology
- C. difficile is an anaerobic toxin-producing, gram-positive bacillus bacteria existing in vegetative and spore forms.
- Spores can survive for months in harsh conditions and outside of the body.
- Spread by fecal–oral contact. Acid-resistant spores pass through stomach to reside mostly in the colon.
- Colonic colonization causes disruptions in barrier functions of the normal microbiome (2).
- C. difficile is noninvasive. Toxins mediate disease:
- Toxins A (enterotoxin) and B (cytotoxin) attract neutrophils and monocytes, degrading colonic epithelial cells and causing clinical disease.
- The hypervirulent strain BI/NAP1/027 of C. difficile produces a much more virulent form of disease. It is associated with higher rates of colectomy and death.
Genetics
No known genetic factors
Risk Factors
- Host risk factors
- Age >65 years
- Hospitalization or long-term health care facility
- Comorbidities, including inflammatory bowel disease, immunosuppression, chronic liver disease, and end-stage renal disease
- Enteral feeding
- Previous C. difficile infection
- Factors that disrupt normal colonic microbiota:
- Exposure to antibiotics (including perioperative prophylaxis) increases risk for C. difficile infection.
- Commonly implicated antibiotics: ampicillin, amoxicillin, clindamycin (most common), cephalosporins, and fluoroquinolones
- Chronic acid suppression may allow more bacteria to reach the colon (2).
- Recurrence from prior infection
- Recurrence rates are ~20%; recurrence more likely with each additional episode (2)
- Can colonize ileum in patients with prior colectomy
- Community-acquired C. difficile infections (no overnight admission in >12 weeks) are more frequent in patients without other risk factors (younger, no recent antibiotic exposure).
Geriatric Considerations
C. difficile is the most common cause of acute diarrheal illness in long-term care facilities. Elderly patients often have multiple risk factors (comorbid disease, antibiotic exposure, medication use).
Pediatric Considerations
- Neonates have a higher rate of C. difficile colonization (25–80%) but are generally less symptomatic than adults (possibly due to immature toxin receptors).
- Frequently serve as carrier for infection in adults
General Prevention
- Antibiotic stewardship program decreases the incidence of C. difficile infection.
- 2010 Society for Healthcare Epidemiology of America (SHEA)/Infectious Diseases Society of America (IDSA) guidelines for prevention (3):
- For health care workers, patients, and visitors:
- Contact precautions, including gloves and gowns, on entry to room
- Alcohol-based hand sanitizers are not effective. Hand washing with soap and water before and after patient interaction is recommended.
- Accommodate patients with C. difficile infection in private rooms, if possible.
- Environmental cleaning and disinfection
- Disinfect with hypochlorite or other spore-killing solution.
- Identify and reduce environmental sources of C. difficile, including the use of nondisposable rectal thermometers.
- Antimicrobial restrictions
- Minimize the frequency and duration of antibiotic therapy. Use particular care when prescribing commonly implicated antibiotics.
- For health care workers, patients, and visitors:
Commonly Associated Conditions
Pseudomembranous colitis, toxic megacolon, sepsis, colonic perforation
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Basics
Description
- A gram-positive, spore-forming anaerobic bacillus that releases toxins to produce clinical disease
- Infection caused by Clostridium difficile is frequently associated with antibiotic use, hospitalization, residence at long-term care facilities, and age.
- Severity of infection can range from diarrhea to pancolitis, perforation, and death.
- System(s) affected: gastrointestinal
- Synonyms(s): C. difficile–associated disease or diarrhea (CDAD); C. difficile infection; C. difficile colitis; C. diff
Epidemiology
Incidence- C. difficile is a common hospital-acquired infection. The incidence is rising (1).
- There are ~15 new cases per 1,000 clinical discharges; higher with increased age (2)
- Rates of complications are also increasing (1).
Prevalence
- C. difficile causes ~25% of all cases of antibiotic-associated diarrhea.
- Prevalence of community-acquired C. difficile infection is increasing. Up to 40% of patients require hospitalization (2).
- C. difficile is a commensurate organism in 2–5% of the adult U.S. population.
Etiology and Pathophysiology
- C. difficile is an anaerobic toxin-producing, gram-positive bacillus bacteria existing in vegetative and spore forms.
- Spores can survive for months in harsh conditions and outside of the body.
- Spread by fecal–oral contact. Acid-resistant spores pass through stomach to reside mostly in the colon.
- Colonic colonization causes disruptions in barrier functions of the normal microbiome (2).
- C. difficile is noninvasive. Toxins mediate disease:
- Toxins A (enterotoxin) and B (cytotoxin) attract neutrophils and monocytes, degrading colonic epithelial cells and causing clinical disease.
- The hypervirulent strain BI/NAP1/027 of C. difficile produces a much more virulent form of disease. It is associated with higher rates of colectomy and death.
Genetics
No known genetic factors
Risk Factors
- Host risk factors
- Age >65 years
- Hospitalization or long-term health care facility
- Comorbidities, including inflammatory bowel disease, immunosuppression, chronic liver disease, and end-stage renal disease
- Enteral feeding
- Previous C. difficile infection
- Factors that disrupt normal colonic microbiota:
- Exposure to antibiotics (including perioperative prophylaxis) increases risk for C. difficile infection.
- Commonly implicated antibiotics: ampicillin, amoxicillin, clindamycin (most common), cephalosporins, and fluoroquinolones
- Chronic acid suppression may allow more bacteria to reach the colon (2).
- Recurrence from prior infection
- Recurrence rates are ~20%; recurrence more likely with each additional episode (2)
- Can colonize ileum in patients with prior colectomy
- Community-acquired C. difficile infections (no overnight admission in >12 weeks) are more frequent in patients without other risk factors (younger, no recent antibiotic exposure).
Geriatric Considerations
C. difficile is the most common cause of acute diarrheal illness in long-term care facilities. Elderly patients often have multiple risk factors (comorbid disease, antibiotic exposure, medication use).
Pediatric Considerations
- Neonates have a higher rate of C. difficile colonization (25–80%) but are generally less symptomatic than adults (possibly due to immature toxin receptors).
- Frequently serve as carrier for infection in adults
General Prevention
- Antibiotic stewardship program decreases the incidence of C. difficile infection.
- 2010 Society for Healthcare Epidemiology of America (SHEA)/Infectious Diseases Society of America (IDSA) guidelines for prevention (3):
- For health care workers, patients, and visitors:
- Contact precautions, including gloves and gowns, on entry to room
- Alcohol-based hand sanitizers are not effective. Hand washing with soap and water before and after patient interaction is recommended.
- Accommodate patients with C. difficile infection in private rooms, if possible.
- Environmental cleaning and disinfection
- Disinfect with hypochlorite or other spore-killing solution.
- Identify and reduce environmental sources of C. difficile, including the use of nondisposable rectal thermometers.
- Antimicrobial restrictions
- Minimize the frequency and duration of antibiotic therapy. Use particular care when prescribing commonly implicated antibiotics.
- For health care workers, patients, and visitors:
Commonly Associated Conditions
Pseudomembranous colitis, toxic megacolon, sepsis, colonic perforation
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