C. diff (also known as Clostridioides difficile, Clostridium difficile or C. difficile) is a bacterial infection of the intestinal tract. It is highly contagious as infecting spores are easily spread and can last on surfaces for extended periods. Its primary symptoms are watery diarrhea, fever, nausea and abdominal pain. C. diff is strongly associated with antibiotic use. While a vital treatment component for many afflictions, including C. diff, antibiotics can also eliminate protective bacteria, decreasing our bodies’ ability to fend off infection. Says Dr. Herman, “C. diff is almost always an infection that occurs after somebody has been on antibiotics. It can occur without prior use antibiotics, but that is much less likely.” The CDC estimates nearly half a million C. diff infections occur in the U.S. each year.
How is C. diff Transmitted?
C. diff is spread through ingestion of bacterial spores. Invading spores colonize the intestinal tract. The germ is highly contagious and prevalent both in and outside healthcare settings. It is found in soil, air, water, human and animal fecal matter, and food products such as produce and processed meats. It can contaminate surfaces for weeks and is even somewhat resistant to alcohol-based hand sanitizers.
Elderly hospital patients and residents of nursing home and assisted living facilities, who tend to be on antibiotics and in daily contact with others taking antibiotics, are especially vulnerable. Says Dr. Herman, “it is very contagious because these spores can live in the environment for a long period of time. If you ingest the spores after touching objects or surfaces contaminated by them and then eat or touch your mouth without thoroughly washing your hands, then infection can easily be spread.”
What are Top Risk Factors for C. diff?
The majority of C. diff infections occur in elderly persons taking antibiotics, particularly those who are or have been in a hospital or healthcare setting or live in a nursing home or assisted living facility. “Again, it is unusual to get it if you have not been on antibiotics,” relates Dr. Herman. “The elderly are more at risk of getting it than younger people. Being in the hospital places you at higher risk than being an outpatient, even though you can get it as an outpatient too. Invading spores can live for a long time on surfaces in patients’ rooms, on their hands, on their clothing, on stethoscopes of healthcare workers, and it can easily be transmitted even between hospital roommates. If patients are in a semi-private room and one patient has it, then there is a good chance the other person will become infected as well.”
Additional high-risk groups include those undergoing treatment for other conditions. “Anybody who has severe comorbid illnesses is at risk,” says Dr. Herman. “Other medical conditions such as cancer, poor nutritional status, or renal failure, which make the body weaker, will increase the risk. Other risk factors include obesity, cancer chemotherapy, medical implants, and inflammatory bowel disease, to name a few.”
Which Antibiotics are Greatest Offenders in Enabling C. diff Infection?
Healthy intestines contain up to 2,000 different kinds of bacteria, many providing vital protection from infection. Antibiotics prescribed to treat an infection tend to kill protective bacteria in the process. Individuals who are not taking antibiotics by and large have enough healthy intestinal bacteria to successfully fend off C. diff infections.
“One of the most important things is to not prescribe unnecessary antibiotics,” stresses Dr. Herman. “About 50% of antibiotics prescribed are unnecessary. That’s why we make such a big deal about stopping antibiotics, and not starting them if they are not necessary. Antibiotics can be life-saving, but they can be life-threatening as well if used improperly or unnecessarily.”
Certainly, antibiotics play a key role in the health and wellness of millions of patients. The key is to avoid the most offending ones when satisfactory alternatives are available. The following are some of the antibiotics that are most likely to compromise intestinal immune systems leading to C. diff infection:
- Fluoroquinolones, such as ciprofloxacin and levofloxacin
What are the More Severe Symptoms of C. diff Infection?
While C. diff symptoms are generally mild to moderate, some infections can become life threatening. States Dr. Herman, “It can range from being asymptomatic, to someone who has diarrhea, which is usually watery, loose, foul-smelling stools, three or more times per day – to a fulminant disease, where people develop something called a ‘toxic megacolon’ in which their colon gets big and dilated, and can even perforate, which may be fatal.” The Mayo Clinic compiled the following list of extreme symptoms:
- Watery diarrhea multiple times a day
- Abdominal cramping and pain
- Rapid heart rate
- Blood or pus in the stool
- Loss of appetite
- Weight loss
- Swollen abdomen
- Kidney failure
- Increased white blood cell count
How is C. diff Treated?
The first step in treating C. diff is immediate cessation of other antibiotics if possible. Depending upon the severity of infection, the treatment plan may include the following:
- Antibiotics – Ironically, antibiotic therapy is the standard treatment for C. diff. As Dr. Herman details, “The most common, or first choice, is oral vancomycin. Intravenous vancomycin is not effective against C. diff infection. Oral vancomycin is administered every six hours, usually for 10 days. We used to prescribe Flagyl or metronidazole, but that has been shown to be inferior, and therefore it is no longer recommended as a first choice. A newer medicine called Dificid or fidaxomicin, is also a first choice. The problem is that it is considerably more expensive than vancomycin. It has not been shown to be any better, in terms of response. It has been shown to result in fewer relapses, but because of its cost, it is usually not the first choice unless the patient is felt to be at a very high risk for C. diff relapse. We usually use vancomycin first because it has been shown to be just as effective and it works well for a majority of patients.” Treatment guidelines also recommend these same antibiotics for recurrent infection. The effectiveness of antibiotic therapy declines with each subsequent recurrence. In certain patients, some antibiotics may have harmful effects.
- Fecal Microbiota Transplant (FMT) – Also known as a stool transplant, FMT has been shown highly effective in treating recurrent C. diff. The procedure restores protective bacteria by transplanting healthy fecal matter to the infected intestinal tract.Probiotics – Available over the counter, probiotics contain organisms such as bacteria and yeast. They are popular among patients, though substantive medical evidence of their effectiveness is limited. As Dr. Herman puts succinctly, “There’s really no good evidence of a benefit to taking probiotics while you’re on antibiotics. In fact, the antibiotics may kill the probiotics.”
- IV Infusion – An expensive, one-time treatment, a monoclonal antibody called bezlotoxumab is given through IV infusion. This procedure has proven effective in decreasing C. diff recurrences in patients who have suffered one or more relapses. It must be infused as an outpatient while the patient remains on oral treatment for recurrent C. diff infection. Although expensive, it may be cost effective if it prevents another recurrence and possible hospitalization for the patient.
What Treatments are Available for Recurrent C. diff Infections?
While most C. diff infections are treated effectively with standard antibiotic therapy, the infection does have a significant rate of recurrence. As stated by the NIH US National Library of Medicine, 20 to 30% of those afflicted experience recurrent or persistent symptoms, often at increasing rates. It may be difficult to distinguish between recurrence from the same infection strain or a new infection.
Surprisingly, recurrent C. diff is not associated with therapy resistance. Therefore, repeat infections can be treated with the same regimen used to treat the first episode. However, treatment recommendations become less straightforward. Non-antibiotic treatments, including probiotics, fecal transplant and IV infusion are often recommended for second and recurrent infections. Tapering doses of oral vancomycin or fidaxomicin may also be useful.
What are Best Practices for C. diff Prevention?
“The most important thing is to limit non-essential antibiotics. If they’re not necessary, they should not be given,” emphasizes Dr. Herman. Uncompromised intestinal immune systems with abundant protective bacteria effectively stave off C. diff infection to a high degree. Antibiotics strongly associated with infection should be avoided. And antibiotic use should be targeted rather than generalized.
In healthcare facilities, nursing and assisted care facilities, as well as family homes and other highly used areas, preventing transmission means cleaning thoroughly anywhere many hands go – doorknobs, faucet knobs, countertops, food trays, sign-in pens, tablet screens, wall switches, stair and elevator railings, and other highly touched surfaces. A fortunate consequence of COVID-19 is that many of these protocols are already in place. Many hospitals are giving inpatient rooms intensive “terminal cleanings” between patients, even using robotic ultraviolet machines to kill offending spores.
Personal hygiene is extremely important, especially so for those taking antibiotics and spending their days in and around healthcare and shared-living environments. Just as COVID-19 has taught us the importance of washing hands, likewise it is vital to reducing risk of C. diff infection, which requires hand-to-mouth transmission. Also be mindful to clean personal items such mobile phones, keychains and billfolds.
How Can ID Care Help Your Organization Stay Infection-Free?
ID Care leads the way in the care and control of infectious diseases such as COVID-19 and
C. diff. As the region’s largest private network of infectious disease providers, ID Care experts treat patients in ten dedicated outpatient locations and provide care and consultation to over 130 healthcare organizations across New Jersey. This team of dedicated, highly trained experts bring experience gained through treating the entire spectrum of infectious diseases, from common to rare. ID Care is equipped with state-of-the-art technology and continues ongoing research to yield more and more effective treatments and prevention methods.
To consult with our team on designing and implementing a program to control C. diff and other contagions that threaten your patients, staff and facilities, call 908-281-0221 or visit ID Care Partners today.