Update On Clostridium Difficile

Clostridium difficile (C.diff) infection (CDI) is the most common US healthcare pathogen-associated infection with over 450,000 cases and 29,000 deaths per year. If you work in healthcare, you’ve likely heard of CDI… but where does this bug come from and what can we do about it?

30-40% of households, 20% of grocery meats, and 10-20% of hospital patients are colonized with C.diff. Consequently, some patients present with C.diff on admission to the hospital and CDI is activated from antibiotics, antacids, immunosuppressants, etc. Transmission also occurs from symptomatic and asymptomatic patients via spores carried on staff members’ hands, clothing, equipment, and the environment. One study showed that if you had the misfortune to be admitted to a room previously occupied by a patient with CDI, you have a 2.4x higher risk of contracting CDI. Additionally, if the previous occupant was NOT diagnosed with C.diff but ONLY received antibiotics as part of their care, you’re still at an increased risk likely from asymptomatic colonization.

So how about diarrhea in the ICU? We used to be so trigger happy about ordering C.diff in anyone who had new onset diarrhea, but the reality is only 5% of ICU diarrhea is related to CDI. Close to 70% is due to medications, chemotherapy, and tube feeds and 25% is due to laxatives, enemas, suppositories in the preceding 24 hours.

Cliff the Beagle – the world’s best test for C.diff

To date, the C.diff toxin enzyme immunoassay (EIA) remains the best test for CDI although it isn’t always accurate. A PCR test only tests for the gene that creates toxin, but does not shed light on whether or not that toxin is being produced. The C.diff antigen tests for glutamate dehydrogenase, an enzyme produced by all C.diff organisms. A positive toxin is concerning for CDI. A negative toxin, negative antigen or negative toxin, positive antigen are equivocal and reassuring. As a side note, Cliff the Beagle has been shown to have 100% sensitivity and specificity in identifying C.diff in stool! How cool! 🙂

What’s the best treatment for CDI? In the case of mild disease, oral vancomycin and metronidazole seem equivocal; however in our critically ill ICU patients, we always opt for oral vancomycin. More novel agents like fidaxomicin offer the advantage of decreased CDI recurrence rate but similar efficacy when compared to oral vancomycin. How about combining oral vancomycin AND IV metronidazole? There’s some retrospective evidence in favor of combining therapies to improve mortality rates in critically ill patients.

How about CDI recurrence? We should treatment by reestablishing control with oral vancomycin therapy and consider a vancomycin taper/pulse which, in theory, should target newly created C.diff spores. Other considerations include fidaxomicin, a fecal microbiota transplant (FMT), and bezlotoxumab – a $4,000/dose monoclonal antibody targeted at the toxin.

What’s your experience with CDI? Any crazy recurrences? Toxic megacolon? Drop me a comment below! 🙂

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  1. Hello,Dr.Rish what is the different of amebiasis to CD I? It’s the same infection right.how about flagyl is it also antibiotic for stool infection?how fast the transmitted to a person to person? Do a rubbing alcohol can used if no water to wash hands around the place?

    I’m just curious for this kind of ill CD I .I just this commonly I know the diarrhea comes from parasites or amebiasis.

    Thank you to this very important information so many cases also in Philippines .and mostly children died in diarrhea.but I never heard cdi.

    Be blessed,

    • Amebiasis is caused by a parasite, Entamoeba histolytica, and is treated differently based on where the infection is (intestine, liver abscess, etc.). CDI is caused by a bacteria, Clostridium difficile, most commonly treated with oral vancomycin.

  2. Great post Rishi? I’m glad there are great antibiotics available that aren’t PCN, or in the PCN family. Having had an anaphylaxis reaction to PCN, and then a serious allergic reaction to Cephalosporin, I feel limited when it comes to a strong antibiotics. And, PCN allergy is becoming more, and more common. Something that I’ve always thought was poor practice in the OR is pushing meds, (especially antibiotics) out of a syringe, into the air before inserting it into the patients IV. Of course we don’t want air in the syringe/IV, but it can be accomplished differently. With all the very resistant bacteria out there now, we all need to do our part, no matter how small. Just saying.

    • Great points! I feel like a lot of what we do in the operating room is for the sake of speed and efficiency. It’s hard to tell if these things really compromise patient safety (ie, increased rates of infection), but occasionally you’ll see an article addressing a belief which is debunked. For example, JCAHO makes us wear bouffant/disposal caps in the OR although some evidence suggests cloth caps may protect better against contamination.


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