Clostridioides difficile (formerly known as “Clostridium difficile”) is one of the most common healthcare-associated infections. This organism is an anaerobic, spore-forming, toxin-producing bacterium capable of causing severe diarrhea, pseudomembranous colitis, toxic megacolon and death.
Over the past several years, the U.S. has seen an increase in rates of nationwide, states have reported increased rates of C. difficile infection, noting more severe disease and an associated increase in mortality. C. diff infection remains a disease mostly associated with healthcare (at least 80%). Patients most at risk remain the elderly, especially those using antibiotics. Although the elderly are still most affected, there is more disease being reported in traditionally ‘low risk’ persons such as healthy persons in the community, and peripartum women.
The increase in cases of C. diff infection with more severe disease and mortality may be largely due to the emergence of a new epidemic strain of C. difficile, known by its names assigned by various typing schemes as restriction enzyme analysis type BI, North American Pulsed Field type 1 (NAP1), or PCR ribotype 027. This strain appears more virulent possibly due to its increased production of toxins A and B and an additional toxin known as binary toxin. It is also more resistant to a commonly-used class of antimicrobials known as the fluoroquinolones.
One of the primary risk factors for acquiring Clostridioides difficile infection (CDI) is antibiotic use. Antibiotics disrupt the normal microbial flora of the gastrointestinal tract thus allowing more resistant organisms to flourish. Minimizing the use of antibiotics to circumstances in which they are truly needed and decreasing the use of broad- spectrum antibiotics can minimize the risk of disease.
Transmission of Clostridioides difficile
Clostridioides difficile is shed in feces and transmission occurs as a result of fecal-oral transmission. Infected or colonized patients are the primary reservoir for infection. However, any surface, device, or material (e.g., commodes, bathing tubs and electronic rectal thermometers) that becomes contaminated with feces may serve as a reservoir for the Clostridioides difficile spores that are able to survive outside the body for prolonged periods. Clostridioides difficile spores are transferred to patients mainly via the hands of healthcare personnel who have touched a contaminated surface or item.
Prevent and control transmission of infection
Hospitals and long-term care facilities have been able to significantly reduce transmission and control outbreaks by implementing an array of infection prevention strategies including the following:
- Place patients in a private room on contact precautions upon suspicion of CDI. If single rooms are not available, cohort patients with CDI and provide a dedicated commode for each patient.
- Use of gown and gloves prior to entering the room of a patient with or suspected of having CDI.
- Strict adherence to hand hygiene before entering a patient room and after glove removal.
- Gloves should be changed, and hand hygiene performed if visibly soiled or if potentially contaminated during a patient procedure.
- Use of dedicated patient care items and equipment.
- Cleaning and disinfecting all medical equipment prior to use on another patient.
- Daily and terminal cleaning and disinfecting the room of a CDI patient with special attention to all high touch surfaces.
Many facilities have also implemented the following changes as a result of an outbreak or high endemic levels of CDI:
- Use of bleach or EPA-registered product effective against Clostridioides difficile spores for daily and terminal cleaning of CDI patient rooms. (See section on Environmental Cleaning)
- Use of soap and water for hand hygiene when caring for a patient with Clostridioides difficile.
- Elimination of the use of electronic rectal thermometers.