Clostridioides difficile infection: an update on its identification, management and prevention
Intended for healthcare professionals
Evidence and practice    

Clostridioides difficile infection: an update on its identification, management and prevention

Luís Carlos do Rego Furtado Clinical nurse specialist in medical-surgical nursing, Hospital do Divino Espirito Santo, Ponta Delgada, Portugal

Why you should read this article
  • To enhance your knowledge of the pathophysiology, transmission and treatment of Clostridioides difficile infection, and to be aware of its growing community expression

  • To update your knowledge and ensure your practice is based on the latest evidence regarding the measures for preventing C. difficile cross-infection

  • To enhance your knowledge of patient education regarding C. difficile infection in community settings

Clostridioides difficile infection is increasing in expression in hospital and community settings, making it a significant public health issue. It is essential to reinforce knowledge of the disease, including its symptoms, diagnosis, treatment and effective prevention and control measures, to reduce the risk that this disease represents for patients. This article outlines the established risk factors for C. difficile infection, relevant aspects of its epidemiology, diagnostic testing, treatment and preventive measures.

Primary Health Care. 32, 4, 23-29. doi: 10.7748/phc.2021.e1755

Peer review

This article has been subject to external double-blind peer review and checked for plagiarism using automated software

Correspondence

luis.cd.furtado@outlook.pt

Conflict of interest

None declared

do Rego Furtado LC (2021) Clostridioides difficile infection: an update on its identification, management and prevention. Primary Health Care. doi: 10.7748/phc.2021.e1755

Published: 01 August 2022

Published online: 22 December 2021

Infection with Clostridioides difficile, formerly known as Clostridium difficile, is the most common enteric infection encountered in hospitals and nursing homes (Ragusa et al 2018) and is a concerning nosocomial and public health issue. A pan-European point prevalence study demonstrated that 48% of gastrointestinal infections in hospitals were caused by C. difficile, and it accounted for around 8% of all healthcare-associated infections (Nagy 2018).

The epidemiology of C. difficile infection (CDI) has changed over the years. It is no longer a disease exclusively associated with hospitals – it is now found in the community, indicating that a wider range of risk factors need to be considered to identify high-risk patients early (Bloomfield and Riley 2016). NHS trusts in England reported 13,286 CDI cases between 1 April 2017 and 31 March 2018 (Public Health England (PHE) 2018). This translates to a small increase of around 3% from 2016/2017 (n=12,845) and a decrease of 76% from 2007/2008 (n=55,498).

Pathophysiology and transmission

C. difficile is an anaerobic Gram-positive bacillus existing in spore form and a vegetative state. These spores are abundant on many surfaces, equipment and the hands of healthcare staff. The infection is transmitted via the faecal-oral route (McDonald et al 2018).

C. difficile is a non-invasive organism that colonises the large intestine, so host intestinal microorganisms prevent colonisation. The loss of these intestinal microorganisms due to exposure to antibiotics, the presence of virulent strains of C. difficile and a suboptimal host immune response leads to the clinical expression of the disease (McDonald et al 2018).

In CDI, diarrhoea and colitis are caused by the release of enterotoxic and cytotoxic proteins. Forms of the disease, from least to most severe, include (Bagdasarian et al 2015):

  • Asymptomatic carriage.

  • Antibiotic-associated colitis without pseudomembrane.

  • Pseudomembranous colitis.

  • Fulminant colitis with myonecrosis.

Profuse watery, green, foul-smelling or bloody diarrhoea, along with abdominal cramps, are cardinal signs of pseudomembranous colitis. Peripheral blood polymorphonuclear leucocytosis and an increased number of faecal leukocytes are other important features. High fever also can occur. When pseudomembranous colitis presents without diarrhoea, a delay in diagnosis can be lethal, leading to toxic megacolon or perforation of the colon (Surawicz et al 2013, Bagdasarian et al 2015).

Key points

  • Clostridioides difficile infection (CDI) is no longer a disease exclusively associated with hospitals – it is now found in the community

  • Significant risk factors for community-acquired CDI include antibiotic and simultaneous corticosteroid use, inflammatory bowel disease, hematologic neoplasia, kidney failure and diabetes mellitus

  • CDI treatment is indicated only in patients with diarrhoea who have been diagnosed with CDI due to toxigenic C. difficile

  • Prevention involves ensuring that the conditions in healthcare organisations reduce the risk of CDI, and nurses need to be aware of the necessary infection prevention and control procedures

Risk factors

Patient-related factors

Well-established host-related risk factors include being aged over 65 years, inflammatory bowel disease, immunodeficiency, haematological neoplasia, malnutrition and decreased serum levels of albumin (hypoalbuminemia), in addition to previous healthcare exposure within the past 90 days and a hospital stay of seven or more days (Álvarez-Hernandez et al 2018). Malignant neoplasia, chemotherapy and human immunodeficiency virus (HIV) infection result in immunosuppression, which is also related to CDI. Patients who have undergone solid organ transplantation are at increased risk of contracting hospital-acquired CDI. A recent history of appendicectomy, nasogastric tube placement and abdominal surgery are further high-risk parameters (Aquina et al 2016).

Induced dysbiosis

Dysbiosis is the disruption of the normal intestinal flora. It describes a microbial imbalance or maladaptation, and is associated with diseases that can occur in several organ systems (Zhou and Zhi 2016). Antibiotic use is the leading risk factor for an individual to develop CDI through dysbiosis; therefore, all antibiotics are risk factors for CDI. Box 1 shows the levels of risk of CDI associated with various antibiotics.

Box 1.

Levels of risk of Clostridioides difficile infection associated with various antibiotics

High risk

  • Fluoroquinolones

  • Second-generation and third-generation cephalosporins

  • Clindamycin

  • Aminopenicillins

  • Broad-spectrum penicillin with inhibitors, except for piperacillin with tazobactam

Moderate risk

  • Macrolides

  • Trimethoprim

  • Sulfamethoxazole

  • Other penicillins, for example ampicillin

  • Sulphonamides

Low risk

  • Aminoglycosides

  • Bacitracin

  • Metronidazole

  • Teicoplanin

  • Vancomycin

  • Rifampicin

  • Chloramphenicol

  • Tetracycline

  • Carbapenems

  • Daptomycin

  • Tigecycline

(Kukla et al 2020)

Significant risk factors for community-acquired CDI include antibiotic and simultaneous corticosteroid use, inflammatory bowel disease, hematologic neoplasia, kidney failure and diabetes mellitus (Furuya-Kanamori et al 2015). The association between proton pump inhibitors and CDI is controversial (Kwok et al 2012); however, proton pump inhibitors restrain gastric acid secretion and may thus contribute to the pathogenesis of CDI by altering the intestinal flora (Cruz-Betancourt et al 2016, Freedberg et al 2016).

Environmental and organisational factors

Hospital wards, intensive care units and long-term care facilities such as nursing homes are major reservoirs for C. difficile. The hands of healthcare staff, environmental contamination through workbenches, commodes, bathtubs, thermometers, stethoscopes and other items carry a significant risk of cross-infection (Simmering et al 2015). Other factors related to CDI include low bed turnover, since prolonged hospitalisations mean that there is a greater probability of contracting infection, and hospitals with an academic affiliation, large urban hospitals and teaching hospitals (Puro et al 2020). This is because these hospitals often admit the most complex patients, who are more vulnerable and may have greater exposure to the risk factors associated with CDI.

Diagnostic testing

Diagnostic testing for CDI is indicated when a patient has diarrhoea that is not attributable to an underlying condition (Surawicz et al 2013). The efficacy of diagnostic tests is increased by only testing patients for whom CDI is clinically probable. Testing should be avoided in patients who have taken a laxative within the previous 48 hours, and non-diarrhoeal stool specimens should be rejected as a measure of increasing testing specificity.

For laboratory diagnosis of CDI, the use of two-stage algorithms is recommended – first a screening test that has a high sensitivity for C. difficile, such as the nucleic acid amplification test to detect the toxin gene or an enzyme immunoassay to detect glutamate dehydrogenase, followed by a highly specific test that detects free faecal C. difficile toxins (Crobach et al 2016).

Treatment

CDI treatment is indicated only in patients with diarrhoea who have been diagnosed with CDI due to toxigenic C. difficile. In antibiotic selection, it is necessary to determine whether the patient has an initial infection or a recurrent infection and the severity of the episode. Oral metronidazole and vancomycin are the most widely used antibiotics in mild and moderate CDI. Treatment with fidaxomicin is an alternative to vancomycin, and has a lower recurrence rate (McDonald et al 2018).

The presence of peripheral blood polymorphonuclear leucocytosis, lactic acidosis or hypoalbuminemia indicates severe CDI. In patients with severe disease, radiographic imaging can be considered to identify colonic dilation, colonic wall thickening, pericolic stranding and ascites. Toxic megacolon, along with distension, pneumoperitoneum (the presence of air inside the abdominal cavity) and perforation, can occur in patients with severe infection. Toxic megacolon is associated with high morbidity and mortality, and surgical management is necessary in most cases. Surgical intervention is warranted when there are clinical complications such as massive haemorrhage, perforation or peritonitis, or medical therapy if has failed to control the disease (McDonald et al 2018). This would typically be a partial or extended colectomy, depending on the extent of the impairment of the colon.

Antibiotics for fulminant colitis include enteral vancomycin and parenteral metronidazole. Monitoring serum creatinine levels is vital when using high doses of vancomycin. Continued treatment with the antibiotic presumed to have caused the infection prolongs diarrhoea and increases the risk of treatment failure and recurrent infections, so the antibiotic should be discontinued. Patients with CDI who are clinically stable can be treated as outpatients after being informed about infection control measures (McDonald et al 2018, Reveles et al 2018).

Prevention and control

Surveillance, reporting, audit and governance

Healthcare-associated infection prevention and control is one of the main components of the NHS Outcomes Framework (Department of Health (DH) 2014), and is reflected in its fifth domain, which aims to treat and care for people in a safe environment, and to protect them from avoidable harm. This framework is the primary assurance mechanism for monitoring the progress of NHS England nationally and aims to improve the quality of care throughout the NHS (DH 2014). To accomplish this, a structure is in place so that the information necessary to produce data on the indicators established by the framework can be obtained effectively and reliably, since these are essential when making decisions and are highly relevant in healthcare organisations.

PHE has an enhanced reporting system for certain infections, including C. difficile. Mandatory requirements for NHS acute trusts to report CDI cases that fulfil the case definition became effective from 1 April 2007 for all patients aged two or more years, and have been mandatory since 2004 for patients aged 65 years and over (PHE 2017, 2020).

PHE’s data capture system provides an integrated data reporting and analysis system for the mandatory surveillance of healthcare-associated infections, including CDI, and it applies to acute trusts in the NHS and independent sector in England (PHE 2017, 2020). Data obtained from epidemiological surveillance is essential in monitoring the progression of healthcare-associated infections, including CDI, providing a set of important and robust information regarding its epidemiology with the aim of improving the quality of care and promoting patient safety culture. Data are also used for benchmarking (PHE 2020).

NHS England mandates that commissioners use the NHS Standard Contract (NHS England 2021a) for all contracts for healthcare services other than primary care. This document identifies that patients’ exposure to CDI risks can be reduced by adopting high hygiene and cleanliness standards. It also emphasises that an increased incidence of C. difficile in a trust compared with the national rate may indicate issues with its infection prevention and control procedures (NHS England 2021a), thus assigning direct responsibility to the healthcare organisation if the outcomes deviate from the national trend.

NHS England (2021a) determined that NHS trusts and foundation trusts must reduce CDI rates to threshold levels set by NHS England and NHS Improvement. These thresholds are established for each trust, thus making it possible to establish trends and monitor trusts’ performances over time. They are derived from a 2019 calendar year baseline to avoid the effects of the coronavirus disease 2019 (COVID-19) pandemic (NHS England 2021b).

Clostridioides difficile infection prevention and control measures

Preventing and managing infection in health and social care is the responsibility of all staff. It is also an integral element of patient safety programmes, applying to all health and social care organisations regardless of the patient setting or care provider (Royal College of Nursing 2017).

One major cause of transmission is the spread of C. difficile spores via contaminated environmental surfaces, equipment and hands, so reduction must focus on effective hand hygiene, the use of appropriate personal protective equipment (PPE), and effective cleaning and disinfection (Dubberke et al 2014). Nurses have a major responsibility in preventing and controlling infection as part of their daily activities. Strategies for preventing and controlling healthcare-associated infections are continually changing, so up-to-date knowledge of these is necessary to provide safer patient care by minimising cross-infection (Nasiri et al 2019).

Prevention involves ensuring that the conditions in healthcare organisations reduce the risk of CDI. Healthcare staff need to be aware of the necessary infection prevention and control procedures, including the importance of effective handwashing and using disposable items such as PPE and certain medical equipment and devices. When faced with a CDI case or outbreak it is essential to enact strict enteric precautions and isolation for all patients who develop diarrhoea (Read et al 2020).

Infection prevention and control is effective in decreasing C. difficile rates during outbreaks. Standard precautions may be less effective when C. difficile rates are at stable, endemic levels, while other control methods such as antimicrobial stewardship may have the most benefit once a robust horizontal infection control programme is in place (Hota et al 2020).

Table 1 outlines core strategies for CDI prevention in acute settings.

Table 1.

Core strategies for Clostridioides difficile infection (CDI) prevention in acute settings

StrategyExamples of actions that may be taken
Isolation and contact precautions
  • Develop nurse-driven protocols for rapid isolation of patients

  • Ensure patients with suspected CDI are evaluated quickly

  • Place symptomatic patients on contact precautions

  • Maintain contact precautions for 48-72 hours after diarrhoea has resolved

  • Use dedicated patient care equipment

  • Implement daily patient bathing or showering with soap and water

  • Ensure that all staff and visitors use disposable gloves and aprons

  • Consider opening an isolation ward if the infection spread is not halting or reducing

  • Reduce the movement of patients to a necessary minimum

  • All clinical waste and linen from patients with CDI should be considered contaminated

  • Use the same infection control precautions for handling deceased patients as those used for patients who are alive

Confirm CDI in patients
  • Healthcare staff:

    • Assess if testing would be appropriate

    • Discontinue laxatives and wait for at least 48 hours before testing if a patient is still symptomatic

  • Laboratory staff:

    • Implement laboratory procedures to ensure only appropriate specimens are tested

    • Report test results immediately to healthcare providers and infection control staff

Hand hygiene
  • Wash hands with soap and water before and after contact with patients with diagnosed or suspected CDI

  • Wear disposable gloves and an apron during physical contact with patients with CDI and the patient’s immediate environment and body fluids

  • Be aware that alcohol hand-rub is not effective against C. difficile spores

  • Healthcare organisations should audit hand hygiene and adequate use of personal protective equipment among staff caring for patients with CDI

Perform environmental cleaning to prevent CDI
  • Create daily and terminal cleaning protocols with a sporicidal agent – for example 1,000ppm available chlorine – and checklists for patient care areas and equipment

  • Perform terminal cleaning after CDI patient transfers, discharges and deaths with a sporicidal agent or vaporised hydrogen peroxide

  • Clean additional areas contaminated during transient visits by a patient with suspected or confirmed CDI using a sporicidal agent

Develop infrastructure to support CDI prevention
  • Incorporate the reduction of CDI into the organisation’s healthcare-associated infection prevention programme

  • Monitor facility CDI rates and target units with the highest incidence of CDI

  • Educate and train healthcare staff on prevention practices for CDI

  • Provide CDI rates to senior leadership, healthcare providers, laboratory staff, environmental services and other stakeholders

Engage the facility antibiotic stewardship programme
  • Implement an antibiotic stewardship programme

  • Assess the appropriateness of high-risk antibiotics

  • Ensure guidelines on indications for the use of antibiotics are easy to understand and follow

  • All consultants should be responsible for reviewing antibiotic prescriptions during their ward rounds, stopping unnecessary medicines and changing those that do not comply with the guidelines

  • Antibiotics started inappropriately or without sufficient evidence should be stopped

  • Trusts should promote mandatory core training in prudent antibiotic use for doctors, pharmacists and nurses

Patients with diagnosed or suspected CDI should be placed in single rooms. If the number of single rooms available is limited, CDI patients with faecal incontinence should be prioritised because this is associated with an increased risk of transmission. If no single rooms are available, it may be necessary to cohort patients with CDI in a multibed room. If cohorting is required, dedicated commodes or bathrooms should be provided to reduce further cross-infection. It is also essential to cohort patients infected or colonised with the same organisms (Waqar et al 2016).

It is crucial to place patients with suspected CDI on contact precautions before confirmation with a diagnostic laboratory test. Isolation and contact precautions should be in place for at least 48-72 hours after diarrhoea resolves (Dubberke et al 2014). Terminal disinfection using hydrogen peroxide vapour has been associated with reductions in viable C. difficile spores from the environment. Daily surface sporicidal disinfection is also recommended (Kundrapu et al 2012).

Effective hand hygiene is one of the fundamental components in the prevention of CDI transmission. However, C. difficile spores are highly resistant to lysis with alcohol. Therefore, before and after providing care for a patient with CDI, it is recommended that healthcare staff wash their hands with soap and water or antimicrobial soap (4% chlorhexidine gluconate) and water, since this is more effective than an alcohol-based solution at removing C. difficile spores (Edmonds et al 2013).

It is also crucial to reinforce the need for patients and visitors to adopt the recommended hand hygiene practices (Deyneko et al 2016). This can be achieved by promoting self-care capabilities, involving patients and their families in care delivery, sharing knowledge with them and supervising the process, thus enabling them to take an active role in their care wherever their condition allows it (Wanchai and Armer 2018). For patients with limited mobility, nurses need to create the conditions whereby they or properly instructed family members and significant others can conveniently ensure hand hygiene at critical moments and in intermediate periods. This is particularly important in patients who are agitated and in those with dementia because they cannot be made aware of the importance of effective hand hygiene, thus increasing the risk of infection for others.

Healthcare staff must use disposable gloves and an apron when entering a room occupied by a patient with CDI and while caring for these patients, to reduce the risk of cross-infection (Landelle et al 2014).

Patient education

Various suggestions have been made regarding how to empower patients, permitting them to obtain the information and develop the skills they need to make decisions and contribute to their care, by educating them and engaging them in many aspects of infection prevention and control (Seale et al 2015). Examples of areas that patient education should cover include: what CDI is and its symptoms; the risk factors involved in the disease’s development and spread; and the precautions required, once infected, to stop the infection being spread to others.

Patients’ hands can become contaminated with C. difficile at a known rate of 32% (Kundrapu et al 2012). Therefore, they can potentially transmit C. difficile to surfaces, thus playing an important role in CDI recurrence when the spores are ingested from their contaminated hands. Patient bathing can also reduce skin contamination and, if showering is possible, it is more effective than bed bathing in decreasing the rate of positive cultures (Jury et al 2011). For this reason, encouraging patients to wash their hands and shower is an important strategy to reduce the burden of spores in the skin and reduce the risk of cross-infection and potential recurrence, particularly after being discharged from hospital (Kundrapu et al 2012).

Antibiotic stewardship programme

Antibiotic restriction may be one of the most beneficial infection control measures, particularly during CDI outbreaks. Antibiotic stewardship is defined as ensuring that every provider selects the right antibiotic for the right indication (right diagnosis) to the right patient at the right time with the right dose and route, causing the least harm to the patient and future patients, targeting improved patient care and outcomes, and reducing collateral damage and unnecessary costs (British Society for Antimicrobial Chemotherapy 2018).

A stewardship programme can only be successful in a healthcare organisation or setting if the following criteria are met (British Society for Antimicrobial Chemotherapy 2018):

  • There is motivation to improve outcomes for patients, prevent avoidable harm related to antimicrobial prescribing, and recognise the potential and actual effects of antimicrobial resistance.

  • The stewardship programme is established with clear lines of accountability and there is a structure within the organisation or setting that enables the implementation of a stewardship programme.

  • Clinical and executive leadership needs to be provided to and by the programme – it needs high-level support and input from a senior management team and clinical staff. It is essential to overcome any organisational and professional barriers that might hinder the activities of the programme.

Clostridioides difficile infection in the community

Since the mid-1980s the incidence of community-acquired C. difficile has increased considerably in the community (Poxton 2013). Compared with hospital-acquired CDI, patients in the community are younger (median age 50 years versus 72 years), healthier, more likely to be female (76% versus 60%), and less likely to have been exposed to antibiotics (78% versus 94%) (Jones et al 2013). The primary means of CDI transmission in the community are consumption (ingesting spores from contaminated food), environment-to-person or person-to-person via the faecal-oral route (Bloomfield and Riley 2016).

At the community level, residents in long-term care facilities such as nursing homes are particularly susceptible to CDI due to various patient and environmental factors, such as: comorbidities; immunosenescence (the gradual deterioration of the immune system); grouped-living status, including sharing of sanitary rooms; and frequent close contact with healthcare staff (Ho et al 2012).

The following recommendations have been made for the management of CDI in the community (PHE and DH 2008, Harrogate and District NHS Foundation Trust 2021):

  • All cases of diarrhoea among people in the community aged two or more years should be investigated for CDI unless there are clinical or epidemiological reasons not to do so.

  • NHS acute trusts should identify where the patient was when the stool specimen was taken. Cases in which specimens were taken before a patient’s hospital admission or within 48 hours of hospital admission should be termed ‘community-onset CDI’.

  • Healthcare-associated CDI should be defined as ‘that occurring up to four weeks after discharge from a healthcare unit’.

  • An outbreak is defined as two or more cases caused by the same strain related in time and place over a specified period, based on the date of onset of the first case.

  • If more than two cases of diarrhoea that are suspected or known to be infectious occur within a few days at a care home or other community institution, the manager is responsible for reporting this to the local health authorities.

  • Outbreaks of CDI in institutional settings should be investigated as in hospitals.

  • Staff in the community who have diarrhoea should not work unless they have been symptom-free for 48 hours or the diarrhoea is non-infectious.

  • Guidance on prescribing antibiotics in the community should be followed.

  • There should be no restriction on institutions such as nursing homes receiving patients who have had CDI and are now clinically asymptomatic. Care should be taken to communicate the individual’s infection status clearly to staff and GPs.

Conclusion

CDI is the most common enteric infection encountered in hospitals and nursing homes and is increasingly found in the community. It is important that nurses understand the pathophysiology and transmission of CDI, since they will provide the most direct care to patients infected with C. difficile. Nurses should also receive ongoing education and training on infection prevention and control since this is central to effective interventions. Healthcare organisations should ensure that clinical environments reduce the risk of CDI and target any areas for improvement.

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