Clostridioides difficile infection CDI - including symptoms treatment and prevention

Clostridioides difficile (previously known as Clostridium difficile) infection (CDI) is a disease of the large intestine caused by toxins produced by the spore forming bacterium Clostridioides difficile. Around 5 to 10% of healthy people and many children under 2 years of age have these bacteria in the bowel without causing any symptoms. The bacteria are also found in animals such as pigs, horses and cattle.

How Clostridioides difficile is spread

C. Difficile is transmitted from person to person by the faeco-oral route. The main source of transmission is patients with symptomatic infection. These people shed large numbers of C. difficile spores and bacteria in the faeces, resulting in widespread contamination of their skin, bed linen and nearby environmental surfaces.

The spores are resistant to drying and the usual chemical cleaning agents and can therefore remain in the environment for weeks or months. Spores can then be picked up on the hands of patients and healthcare workers and be transmitted to others.

Risk factors for CDI include

  •  Recent antibiotic use
  •  >= 65 years
  • Gastric-acid suppression therapy
  • Significant co-morbidities like inflammatory bowel disease, diabetes, malignancies
  • Abdominal surgery/ Naso-gastric tube in situ
  • Previous CDI
  • Prolonged hospital stays and/or intensive care stay.

Signs and symptoms of Clostridioides difficile infection

The trigger for symptoms is usually a disturbance of the normal bacteria in the gut during antibiotic treatment. This allows C. difficile to colonise (become established in) and multiply in the gut and produce toxins that attack the lining of the gut wall.

Mild, self-limiting symptoms can include:

  • diarrhoea (watery or sometimes bloody)
  • fever
  • loss of appetite
  • nausea
  • abdominal pain.

A serious form of the disease, known as pseudomembranous colitis (severe inflammation of the lining of the gut) has a high death rate if not recognised early and treated appropriately.

Diagnosis of C. difficile infection

Diagnosis is made by laboratory testing of faeces from people with diarrhoea. The usual test for C. difficile toxin does not distinguish between strains. More specialised tests (PCR or polymerase chain reaction tests in a pathology laboratory) are required to detect the epidemic strains thought to be responsible for more severe disease.

Incubation period

(time between becoming infected and developing symptoms)

Incubation period can vary but on an average  2 to 3 days.

Infectious period

(time during which an infected person can infect others)

A person with diarrhoea from  C. difficile  infection is infectious while symptoms persist. C. difficile spores can survive in the environment for weeks or months.

Treatment for C. difficile infection

CDI can be difficult to treat and has a high relapse rate. People with CDI are usually treated with antibiotics as per  the local guidelines. There is no proof that probiotics (such as the natural bacteria in yoghurt) are effective for treatment. Faecal transplantation is reserved for severe disease and/or subsequent recurrences and requires specialist consultation.

Prevention of C. difficile infection

  • The most important measure to prevent the emergence of new strains of C. difficile in Australia is reducing the unnecessary use of antibiotics.
  • Exclude people with C difficile infection from childcare, preschool, school and work until there has been no diarrhoea for at least 24 hours. If working as a food handler in a food business, the exclusion period should be until there has been no diarrhoea and/or vomiting for 48 hours.

At home

If a person with C. difficile infection is being managed at home:

  • practise good hand hygiene with soap and water
  • clean contaminated surfaces with a chemical disinfectant that can kill the C. difficile spores, for example correctly diluted household bleach.

In a residential care facility or hospital

If a person with C. difficile infection is being managed in a residential care facility or hospital, the Australian Guidelines for the Prevention and Control of Infection in Healthcare recommend:

  • good hand hygiene by staff and residents either with soap and water or alcohol based hand gels.  Noting that  if there has been any unprotected exposure (for example, touching the patient or their environment without wearing gloves or direct soiling of the hands) then thorough washing with soap and water should be performed.
  • standard and contact precautions, particularly the correct use of gloves (noting the importance of performing hand hygiene before and after glove use)
  • appropriate use of personal protective equipment
  • disinfection of equipment shared between residents or patients
  • environmental hygiene with a chemical disinfectant that can kill the C. difficile spores (for example, detergent and water, followed by sodium hypochlorite 0.1% - a 1 in 50 dilution of household bleach)
  • placing residents or patients with infection in rooms away from other residents or patients
  • implementing correct infection prevention and control measures if it is necessary to undertake resident or patient transfer or transport.

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