The facts about...

Clostridium difficile infection

What is Clostridium difficile?

Clostridium difficile (C difficile) is a bacterium which can be found in low numbers in the intestine of a small proportion (less than 5%) of the healthy adult population. Normally the 'good' bacteria in the intestine stop it causing any illness. When antibiotics are given to a patient with C. difficile in the intestine, the ‘good’ bacteria may be damaged, and this may allow C. difficile to produce an inflamed intestine (colitis) producing diarrhoea, or sometimes more serious symptoms. The bacterium produces two toxins, which are responsible for the diarrhoea and which damage the cells lining the intestine. Most infections occur in hospitals (including community hospitals), nursing homes etc, but can also occur at home. The bacterium can form spores which enable it to survive in the environment outside the body and which protect it to some degree against cleaning detergents and chemical disinfectants. The bacterium is sometimes found in the intestine of babies, but does not cause illness.

How is the infection caught?

The spores of the bacterium need to get into the mouth of the patient, and are then swallowed. If the ‘good’ bacteria in the intestine have been damaged by antibiotics, there is a chance the patient may become infected. In most cases the disease develops either from contact with faecally conaminated environment or through direct contact with someone with the illness or from healthcare staff.

What does Clostridium difficile cause?

Diarrhoea is the most common symptom but abdominal pain and fever may also occur. In the majority of patients, the illness is mild and full recovery is usual, although elderly patients may become seriously ill with dehydration (loss of water from the body) as a consequence of the diarrhoea. Occasionally patients may develop a severe form of the disease, with serious damage to the intestine, or perforation of the intestine (a hole in the intestine) or death. There are some strains of C. difficile that are more likely to lead to serious disease, and certain hospitals in the UK have experienced outbreaks with these strains.

How is the infection diagnosed?

Infection with C. difficile should be considered in anyone who develops diarrhoea and who is taking an antibiotic, or who has received a course of antibiotics in the past few weeks. In the laboratory the most reliable way of confirming the diagnosis is by finding the toxin produced by C. difficile in the faeces. Such tests are not routinely performed, but are recommended for specimens from patients who have received antibiotics, and also from all patients with diarrhoea who are 65 years or older.

How is Clostridium difficile treated?

Fortunately, most patients develop only a mild illness and stopping the antibiotics that may have caused the diarrhoea (if possible), together with fluid replacement, either by mouth or intravenous drip, usually results in rapid improvement. Often it is necessary to take an antibiotic active against C. difficile itself. Two antibiotics are known to be effective in treatment. Metronidazole taken by mouth is often prescribed as the first choice for non-severe disease; if this is not effective, or for severe disease then another antibiotic, vancomycin, also taken by mouth, may be used. It is important that the full length of antibiotics prescribed for treatment of C. difficile is completed, even if the diarrhoea has gone (otherwise the diarrhoea is more likely to return).
There is a risk of a return of symptoms in about 20-30% of patients and further courses of these antibiotics may be required. Occasionally, other treatments may be tried.

Are probiotics useful in treatment of C difficile?

Probiotics are dietary supplements of live bacteria or yeasts thought to be healthy for the host organism (such as certain yoghurts). Presently there is no good evidence to support the use of probiotics in prevention or treatment of C difficile.

Is C difficile a problem in pregnancy?

The infection is uncommon in pregnancy. The infection is not known to cause abnormalities in the newborn baby of someone who has had the infection in pregnancy. A doctor will be able to recommend a treatment that should be successful in treating the infection during pregnancy.

How is the spread of Clostridium difficile controlled in hospitals and nursing homes?

Patients with diarrhoea may unintentionally spread the infection to other patients, and large outbreaks of C. difficile infection have occurred in hospitals. The ability of this bacterium to form spores (which other causes of diarrhoea, such as salmonella cannot do) enables it to survive for long periods in the environment, e.g. on floors and around toilets. Infected patients should be segregated from non-affected patients, preferably in a single room. Staff should wear disposable gloves and aprons when caring for infected patients. Rigorous cleaning with water and detergent and subsequent disinfection (often with a chlorine product) is probably the most effective way of removing spores from the contaminated environment. Thorough washing of hands by health care staff and visitors, before and after patient contact, can prevent person-to-person spread of this infection. Careful prescribing of antibiotics in hospital (such as avoiding certain types of antibiotics, and stopping antibiotics when no longer required), is important in reducing C difficile in hospital and nursing homes.

Do I need to stay off work or school if I have C difficile infection?

Yes. While you are ill and have symptoms you are infectious. You should not return to work or school until you have been free from diarrhoea for 48 hours.
You should tell your employer you have had C. difficile infection if you work with vulnerable groups such as the elderly, the young, those in poor health, or if you handle food.

Do patients who have had Clostridium difficile diarrhoea in hospital need special care once they have returned home?

People who have had C. difficile infection in hospital do not need special care once they return home. The symptoms of diarrhoea should have gone, or their bowels should have started working normally 48 hours before they are discharged from hospital. They may still be taking antibiotics. The normal procedures of routine hand washing, and cleaning of the environment are all that are needed. Care should be taken in giving antibiotics for a few months after C difficile diarrhoea, as this may trigger a return of the diarrhoea.

If someone at home has C difficile infection, what precautions should be taken to prevent others getting the infection?

If there is someone in the home who is known to be carrying C. difficile, it is important to practice good hygiene in order to reduce the risks of spread to other family members. This is particularly important if there are family members who are healthcare providers. The risk of infection spreading to other healthy family members is very small, but can occur if they have recently had antibiotics. Faecally contaminated surfaces such as toilet seats, bedpans, shower trays and baths may also be involved. When the patient is bedridden, surfaces in their immediate vicinity e.g. bedside tables, bed frames, etc. may be carrying C. difficile spores.

When an infected person is discharged from hospital, the family may be concerned because of the strict precautions that were applied to them while they were in the hospital. It is important to make the family aware that these measures were aimed at preventing the spread of C. difficile to other patients in the hospital who were at particular risk because of their illness or surgery. At home the risks are reduced, but it is important to continue good hygiene to prevent spread to other family members and the environment. Occasionally people can be cleared of infection, only to become re-infected from contaminated surfaces in the home. See Appendix for more detailed advice.

What is being done nationally in the UK to reduce C difficile infection?

You may be aware that some hospitals in the UK have been affected with severe outbreaks of C difficile. Also there has been a large increase in the number of reported cases of C difficile in the UK between 2000 and 2007. Hospitals in the UK have to measure the number of cases, and send this information to the Department of Health. Hospital Trusts have been set targets to reduce the number of cases. Workshops are being held in 2007 to assist professionals in sharing good practice, such as how to improve the prescribing of antibiotics, how to improve cleaning, and how to improve ways of educating healthcare professionals, patients and relatives to control C difficile.

Appendix: Advice for patients and carers at home

Advice for carers:

Good hand washing practice is the single most important infection control measure. Caregivers should wash their hands with soap and water after contact with the infected person or surfaces in their immediate environment (e.g. bedrails, bed cloths, bedside table etc). Clothing, sheets and pillows and linens from the infected patient should be kept separate from the rest of the family laundry and should be laundered by washing at 60°C or above
Clean surfaces in the bathroom and toilet, most particularly including washbasins, baths and toilet bowl, toilet seat and toilet handle using a hypochlorite disinfectant cleaner*
Do not share towels, facecloths, toothbrushes and other personal hygiene items with the infected or carrier person.
Wash hands thoroughly, and hygienically clean kitchen surfaces using hypochlorite disinfectant cleaner before handing or preparing cooked or ready to eat foods.
Where floors or other surfaces** become contaminated with faeces or vomit, they should be hygienically cleaned at once:

Remove as much as possible of the faeces or vomit from the surface, using paper or a disposable cloth
Apply hypochlorite disinfectant cleaner to the surface using a fresh cloth or paper towel to remove residual dirt
Apply hypochlorite disinfectant cleaner to the surface a second time using a fresh cloth or paper towel to destroy any residual contamination
Disposable gloves should be worn if in contact with faeces, and hands should be washed after removing gloves.

Cleaning cloths can easily spread C. difficile spores around the home. They should either be disposable or hygienically cleaned after each use, particularly after use in the immediate area of the patient or the bathroom and toilet used by the patient. This can be done by washing in a washing machine at 60°C
Keep the patient’s immediate environment hygienically clean. The most important surfaces are those which may be contaminated withfaeces e.g. toilets, bath rooms, bedside tables and bed frames. To make these surfaces hygienically clean you need to use a hypochlorite disinfectant cleaner.
Clean floors, carpets and other surfaces daily using vacuum extraction.
In a busy household it is not always possible to keep hand contact surfaces hygienically clean at all times. This is why it is so important to wash hands as frequently as possible.

Advice for the infected person:

Wash your hands frequently, particularly after visiting the toilet.
Avoid preparing food for others. Wash hands before eating food.
Shower frequently, if possible.
If you have diarrhoea, after using the toilet, clean and disinfect the toilet bowl, seat and flush handle using hypochlorite disinfectant cleaner.
Do not share personal hygiene items such as towels, facecloths, and toothbrushes with other family members.

* Domestic hypochlorite bleach cleaners include the “thick bleaches” and “bleach spray surface cleaners”. Domestic thick bleaches usually contain 50,000 ppm (parts per million) available chlorine and should be diluted 1:10 for hygienic cleaning of surfaces. Surface bleach spray cleaners usually contain a minimum of 5000 ppm. All bleaches tend to be inactivated by faeces. For use on relatively clean surfaces such as toilet seats, baths and basins, this is not a problem. However, where there is heavy soiling, e.g. where floors or other surfaces are contaminated with faeces, it is necessary to first “clean” the surface by removing the faeces or vomit (stage 1) and then apply the disinfectant cleaner (thick bleach or spray) to make the surface visibly clean (stage 2). This may, however, leave behind some residual contamination, so it is advisable to reapply the disinfectant cleaner a second time (stage 3) to ensure that the surface is very clean, i.e. free from C. difficile. Detergent and hot water, followed by “thin bleach” can also be used for stages 2 and 3.
** Alternatively, carpets and furnishings can be hygienically cleaned by steam cleaning.