Also known as: Clostridium difficile (C. difficile)

Background Information

Aetiology

Clostridioides difficile is an anaerobic, spore-forming, gram +ve bacillus (rod).

Risk Factors

Primary route of transmission: spore-mediated faecal-oral

 

Risk factors: ^[Ref]

• Recent antibiotic exposure (within 3 months) – most important
  • Cephalosporins, clindamycin, fluoroquinolones and penicillin with beta-lactamase inhibitors carry the highest risk
  • Antibiotics disrupt normal gut flora, allowing C. difficile overgrowth

 

• Use of PPIs (e.g. omeprazole)
• Hospitalisation
• Contact with healthcare facility
• Advanced age
• Immunosuppression
• IBD (esp. ulcerative colitis)
• Recent GI surgery
• Presence of comorbidities (e.g. CKD, cardiac disease, liver disease)

Diagnosis

Clinical Features

Clinical presentation of C. difficile infection is very heterogeneous: ^[Ref1][Ref2]

• Profuse watery diarrhoea (≥3 loose stools in 24 hours without an alternative explanation) – most common presentation
• Abdominal pain / cramping
• Low-grade fever

Fulminant C. difficile infection is characterised by: ^[Ref1][Ref2]

• Toxic megacolon (→ severe abdominal distension)
• Ileus
• Multiple organ dysfunction

Investigation and Diagnosis

Confirmatory Test

Test of choice: stool sample for C. difficile toxin

• Diagnosis of C. difficle infection can be made if there is +ve C. difficile toxin + diarrhoea

Other Tests

Key other tests: ^[Ref]

Laboratory studies	Leukocytosis (often correlates with disease severity) ↑ CRP Findings in severe cases Hypoalbuminaemia (reflects protein-losing enteropathy due to colonic inflammation) ↑ Lactate and ↑ creatinine (from dehydration and AKI)
Colonoscopy findings	Pseudomembranous colitis (raised white / yellow lesions that are irregularly distributed and separate by normal mucosa) (NOT removed by intestinal wall rinsing) Not all patients with C. difficile infection have pseudomembranes, and their absence does not rule out C. difficile infection Colonoscopy should generally be avoided in patients with severe Clostridioides difficile infection due to the risk of perforation and lack of impact on management
Imaging	Imaging is useful to detect complications: Abdominal X-ray / ultrasound can be used to demonstrate toxic megacolon / ileus CT abdomen-pelvis with contrast is useful in those with severe disease

Management

Medication Review

Review any existing antibiotic treatment

• Stop the antibiotic, unless essential (e.g. serious ongoing infection)
• If an antibiotic is essential → switch to an alternative antibiotic with a lower risk of causing C. difficile infection

 

Review the need and consider stopping other medications:

• PPIs (continue only if necessary)
• Medications with GI activity or adverse effects
• Medications that may be problematic if the person is dehydrated (e.g. NSAIDs, ACE inhibitors, diuretics)

Prevention of Spread

Isolation rules:

• Patient should be isolated in a single room with a self-contained toilet and its own hand basin
• The patient should remain isolated until there has been no diarrhoea (types 5–7 on the Bristol Stool Chart) for at least 48 hours, and a formed stool has been achieved (types 1–4)

 

Infection control rules:

• All healthcare workers should wash their hands with soap and water before and
  after contact with patients
  body fluids
  • DO NOT use alcohol handrub as an alternative to soap and water
• All healthcare workers must use disposable gloves and aprons for any physical contact with patients

Antibiotic Treatment

Patients with confirmed C. difficile infection require antibiotic treatment. The choice of antibiotics depends on 1) severity and 2) whether it is a first or recurrent episode

Severity	Features
Mild	NO increased white cell count <3 loose stools per day
Moderate	Increased white cell count but <15 x 109 /L 3-5 loose stools per day
Severe	White cell count >15 x 109 /L Acutely increased serum creatinine concentration (>50% above baseline) Temperature >38.5°C Evidence of severe colitis (abdominal or radiological signs)
Life-threatening	Any of the following Hypotension Ileus (partial or complete) Toxic megacolon CT evidence of severe disease

Life-Threatening Infection

• Oral vancomycin + IV metronidazole
• Seek urgent specialist advice, which may include surgery

Non-Life-Threatening Infection

Type of infection	Recommended antibiotic
1st episode	1st line: oral vancomycin 125mg QDS for 10 days 2nd line: oral fidaxomicin 200mg BD for 10 days 3rd line: oral vancomycin (500mg) +/- IV metronidazole
Further episodes	Relapse (<12 weeks of last resolved episode): oral fidaxomicin 200mg BD for 10 days Recurrence (>12 weeks of last resolved episode): oral vancomycin / oral fidaxomicin

Consider a faecal microbiota transplant in adults with ≥2 previous episodes

References