Clostridioides difficile infection

Clostridioides difficile, previously known as Clostridium difficile (Cattini and Kiernan, 2021), is a Gram-positive anaerobic bacterium which is found in the healthy gut of 3% of adults and 66% of babies (HM Government, 2019). In healthcare settings, it is a leading cause of healthcare-associated infections and infective diarrhoea, and is also a major public health threat (Finn et al, 2021).

A C. difficile infection can kill older and hospitalised patients but is increasingly also being recorded as an infection in otherwise healthy people in the community (De Roo and Regenbogen, 2020). C. difficile spores are heat resistant as well as being resistant to many disinfectants which means an outbreak is difficult to contain, especially in the healthcare setting. Once infected with C. difficile, recurrent infections are common and can be debilitating for some people (Smits et al, 2016).

There are over 380 known strains of

The signs and symptoms of C. difficile infection vary according to its severity. They are classified according to criteria identified in the National Institute for Health and Care Excellence (NICE, 2021a) guidance as:

Non-severe:

• no increase in white cell count
• less than three episodes of loose stools daily (loose enough to take the shape of the container used to sample them)

Moderate infection:

• an increase in white cell count (but less than 15 x 10⁹ per litre)
• three to five loose stools per day

Severe infection:

• a white cell count greater than 15 x 10⁹ per litre, or
• an acutely increased serum creatinine concentration (greater than 50% increase above baseline), or
• a temperature higher than 38.5^°C, or
• evidence of severe colitis (abdominal or radiological signs)
• the frequency of stools may be a less reliable indicator of severity

Life-threatening infection:

• hypotension
• partial or complete ileus
• toxic megacolon – this is rare and occurs when the

The transmission of C. difficile most commonly occurs in healthcare settings through person to person contact or person to surface contact, e.g. when someone touches a surface which is infected with C. difficile. This is the oro-faecal route.

Community transmission does occur, often within households, and C. difficile may also be transmitted in the air, water and soil. C. difficile can be transmitted in food, often as a result of poor hand-hygiene practices (Loo et al, 2016).

A common scenario in which C. difficile infection becomes a problem causing diarrhoea occurs when a hospitalised patient is given antibiotics for another reason (UK HSA, 2022). These antibiotics supress the usual gut bacteria allowing C. difficile to replicate so it starts to overwhelm the individual’s usual bowel flora (Hassoun, 2022), this is termed C. difficile overgrowth (Planche and Wilcox, 2015). A proliferation of C. difficile causes an

If an individual has diarrhoea, it is important to isolate the cause to allow for targeted treatment or a cure to be offered. C. difficile should be suspected in any new cases of diarrhoea in a healthcare setting which are not related to an underlying condition such as inflammatory colitis (UK HSA, 2022). Testing should take place as soon as possible rather than wating for the patient to experience multiple episodes of diarrhoea.

Guidelines suggest patients with diarrhoea (Bristol Stool Chart 5–7) which is not known to be attributable to another cause should be tested for C. difficile. Therefore, all hospitalised individuals over 2 years of age, community patients with diarrhoea aged 65 years or more and community patients under 65 years who present with other signs and symptoms of C. difficile should be tested (HM Government, 2012).

Diagnosis will require the nurse to obtain a specimen of the

The key to the management of diarrhoea is the removal, or reversal of the cause if possible as well as the management of the signs and symptoms of diarrhoea (see: Diarrhoea and Vomiting). For diarrhoea caused by C. difficile, reversing the cause requires stopping the antibiotics which may be contributing to the problem. Although this may resolve the episode of diarrhoea, other antibiotics should be used to treat the infection. NICE (2021c) identify:

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