Clostridium Difficile Infection: Frequently Asked Questions

Marwah Saeed, BSc (Hons), MBBS

Written by: Marwah Saeed, BSc (Hons), MBBS

Updated: January 16th, 2024

In “Clostridium Difficile”, we began discussing Clostridium Difficile Infection (CDI). In this article, we will delve deeper into this topic, but first – let’s start with a quick recap. You may recall that CDI is an infection caused by the bacteria Clostridium difficile or C. diff for short, infecting the large intestine. C. diff can be found everywhere in the environment from soil, air, and water to everyday objects such as doorknobs and counter tops. It can also be found in the intestines of up to 3% individuals, as part of the gut flora (“Clostridium Difficile”, n.d.). Symptoms of CDI can range from mild to severe with typical symptoms being watery diarrhea and abdominal cramping. Severe CDI includes more frequent diarrhea, fever, bloody stool and in some cases even death (“Your risk”, 2022). 

How does C. Diff Spread?

C. diff can live outside the body as spores which are “inactive” or “dormant” forms of the bacteria. C. diff  spores are difficult to kill, persisting for months to years (Bruno-Murtha, 2020). They spread by something known as “fecal-oral transmission” i.e. they are carried from person to person in feces. Poor hand hygiene can help spread C. diff to people or to objects that are touched. They enter the body through the mouth and begin to reproduce in the intestines releasing toxins that damage tissues and destroy cells causing diarrhea and other gastric symptoms (“Clostridium Difficile”, n.d.). Historically CDI was thought to be an infection confined to hospitals and care homes. Not only was antibiotic use common in these facilities but people were in close proximity to each other, and health care providers tended to many patients, increasing the likelihood of transmission. Not to mention, C. diff is hard to kill, without the use of certain disinfectants, so it can persist in the environment. Lately, statistics have been demonstrating an increasing rate of CDI in the community as well (“Clostridium Difficile”, n.d.; Velez, 2022). 

Can antibiotics give you C. Diff?

According to the Centre for Disease Control (CDC), you are 7-10 times more likely to get CDI while on antibiotics or within a few days-weeks after taking antibiotics (“Your risk”, 2022). However, simply using a prescribed antibiotic does not necessarily mean you will get CDI. There are other factors that may make you more susceptible to CDI such as a weakened immune system, being over the age of 65, prolonged hospitalization or living in a nursing home (“Clostridium Difficile”, n.d.). 

So why is C. diff associated with antibiotics? Antibiotics are a type of medication that can help prevent or treat an infection caused by bacteria. Unfortunately, there are instances where antibiotics not only kill the “bad” bacteria but also harm the “good” or “beneficial” bacteria (“Your risk”, 2022). As you may know, the intestines are home to trillions of bacteria, known as the gut flora or gut microbiota, which play a key role in metabolism, immune system and even mood (“Clostridium Difficile:, n.d).  Loss of “good” bacteria disrupts the natural balance of gut flora/microbiota, prompting C. diff to grow and multiply out of control and produce toxins (chemicals) causing your health to suffer. Consequently, it is important to use antibiotics responsibly, as prescribed by health care providers. 

What to do if you are newly diagnosed with C. Diff

If you have been newly diagnosed with CDI, it is essential that you are mindful of good hygiene. This means thoroughly washing your hands with soap and water. Proper hand hygiene involves washing all the surfaces of the hands, wrists and fingers for at least 20 seconds; a rule of thumb that healthcare providers closely follow (“Keeping hands”, 2022). It’s said that singing the “happy birthday” song twice serves as a good 20-second timer. Check out this video on effective hand washing technique by WHO (“WHO: How”, 2015). And don’t forget that alcohol-based hand sanitizers are ineffective against C. diff. Frequently clean high-touch surfaces or common areas with special cleaning products containing chlorine bleach that are sporicidal (spore killing). Try to use a separate bathroom but if you have a shared facility, carefully clean areas such as sinks, toilet seats, flushers and door handles.

If you have friends, loved ones, acquaintances, or colleagues with weakened immune systems, it’s best to avoid contact to limit exposure to C. diff. It’s also recommended that you do not return to work or school until after your symptoms have ended, with some experts even recommending continued contact precautions until least 48 hours post diarrhea cessation to minimize risk of transmission. Speak to your doctor, employer, or your child’ school or daycare center to determine what is best (“Preventing the”, n.d). 

I’ve heard that you can get CDI again- is that true?

Yes! While most individuals will recover, approximately, 1 in 6 patients with CDI can get a recurrent infection and this usually occurs within 8 weeks of a previous episode. Recurrent CDI may be due to a relapse or reinfection i.e. contact with a different strain. With each episode of CDI, the risk of future recurrence increases (“Life after”, 2021; Song and Kim, 2019). So, if you don’t get better or experience worsening symptoms, seek immediate medical help. 

There are steps you can take to minimize transmission of C. diff such as implementing contact precautions, appropriate hand hygiene, and environmental cleaning and disinfection (“Clostridium difficile”, n.d). 

Treatment Options

There are a few treatment options for CDI:

1. Antibiotics – Interestingly, C. diff is treated by the very same category of medications, i.e. antibiotics, which causes it to flourish in the gut. The most commonly used antibiotics include Vancomycin, Metronidazole and Fidaxomicin.  Your health care provider will speak with you about the most appropriate antibiotic for resolution of symptoms and infection (Smith et al., 2022; Velez, 2022). 

2. Fecal Microbiota Transplantation (FMT), also known as stool transplantation – This option is generally considered if antibiotics have proven ineffective or if CDI is chronic.  The purpose is to reintroduce healthy bacteria into the gut making it difficult for C. diff to thrive. This is done through stool donated by a “healthy person” which is introduced into the patient’s gut either by a tube through the mouth or the rectum or as a capsule, famously known as the “poop pill” (Smith et al., 2022; Velez, 2022). The “poop pill” isn’t yet available in the market; that said, it was approved by the FDA earlier this year for adults, 18 years and older, in the United States (“FDA approves”, 2023). 

FMT is offered in centers across Canada and has been approved by Health Canada in the treatment of CDI only; it otherwise remains an experimental treatment in ongoing clinical trials (“Guidance documents”, 2022). Multiple randomized control trials, over the years, have demonstrated that FMT is highly effective in the management of recurrent CDI with rates ranging from 44% to 96% (Hota and Poutanen, 2018). Furthermore, a systematic review and meta- analysis published in 2020 concluded that FMT is safe and effective in managing this condition, but its effects can vary depending upon the delivery method used (Baunwall, 2020).

Can Probiotics Help with C.Diff? 

An option you may have come across for helping with C. Diff is probiotics. Probiotics have been defined as “live microorganisms which when administered in adequate amounts confer a health benefit in the host” (Hill et al., 2014). To put it simply, probiotics are “good microorganisms”, either bacteria, yeast, or mold, which confer health benefits. They are found in dietary supplements and in some foods such as fortified yogurt or fermented milk products (CDHF, 2022).  They can aid in digestion, boost the immune system and may even impact mood and cognition (though it is too soon to say as research remains ongoing) (“Probiotics may”, 2023). Not all probiotics are the same and different microbes may have different effects (Velez, 2022; CDHF 2022). 

Florastor all-in 1 probiotic contains the yeast Saccharomyces boulardii CNCM 1-745 (S. boulardii), a unique strain studied over 65 years and researched in over 130 clinical trials (De Santis, 2023). Research has shown that S. boulardii can reduce the incidence of antibiotic associated diarrhea. Systematic reviews and meta-analysis published in 2017 and 2021 concluded that S. boulardii reduced the risk of antibiotic associated diarrhea and recurrent C. diff infections, respectively (Goldenberg, 2017; Tariq et al., 2021). Moreover, in an experimental trial, it was discovered that S. Boulardii substantially decreased the recurrence rate of C Diff. infection. Among those who received a placebo, 64.7% experienced infection recurrence, while only 34.6% of those taking S. Boulardii encountered the same issue. (Surawicz et. al, 2000).

References

  1. Baunwall, S. M. D., Lee, M. M., Eriksen, M. K., Mullish, B. H., Marchesi, J. R., Dahlerup, J. F., & Hvas, C. L. (2020). Faecal microbiota transplantation for recurrent Clostridioides difficile infection: An updated systematic review and meta-analysis. EClinicalMedicine, 29-30, 100642. https://doi.org/10.1016/j.eclinm.2020.100642
  2. Bruno-Murtha, L. A. (2020, February 20). C. difficile (C. diff): An urgent threat. Harvard Health Publishing. https://www.health.harvard.edu/blog/c-difficile-c-diff-an-urgent-threat-2020022018862
  3. CDHF (2022, November 30). Understanding Probiotics. Canadian Digestive Health Foundation. https://cdhf.ca/en/understanding-probiotics/
  4. Clostridium Difficile (C. Diff). (n.d.). Yale Medicine. https://www.yalemedicine.org/conditions/c-diff-infection
  5. De Santis, A. (2023, February 10). What is Clostridium Difficile (C. Diff)?. Florastor. https://www.florastor.ca/en/pd-The-Problem-Of-Clostridium-Difficile.html
  6. FDA Approves First Orally Administered Fecal Microbiota Product for the Prevention of Recurrence of Clostridioides difficile Infection. (2023, April 26). U.S. Food and Drug Administration. https://www.fda.gov/news-events/press-announcements/fda-approves-first-orally-administered-fecal-microbiota-product-prevention-recurrence-clostridioides
  7. Goldenberg, J. Z., Yap, C., Lytvyn, L., Lo, C. K., Beardsley, J., Mertz, D., & Johnston, B. C. (2017). Probiotics for the prevention of Clostridium difficile-associated diarrhea in adults and children. The Cochrane database of systematic reviews12(12), CD006095. https://doi.org/10.1002/14651858.CD006095.pub4
  8. Guidance document: Fecal microbiota therapy used in the treatment of Clostridioides difficile infection not responsive to conventional therapies. (2022, September 26). Government of Canada. https://www.canada.ca/en/health-canada/services/drugs-health-products/biologics-radiopharmaceuticals-genetic-therapies/applications-submissions/guidance-documents/regulation-fecal-microbiota-therapy-treatment-difficile-infections.html
  9. Hill, C., Guarner, F., Reid, G., Gibson, G.R., Merenstein, D.J., Pot, B., Morelli, L., Canani, R.B., Flint, H.J., Salminen, S., Calder, P.C., & Sanders, M.E. (2014). The International Scientific Association for Probiotics and Prebiotics consensus statement on the scope and appropriate use of the term probiotic. Nature Reviews Gastroenterology & Hepatology, 11(8), 506-514. https://doi.org/10.1038/nrgastro.2014.66
  10. Hota, S., & Poutanen, S. (2018, June 18). Fecal microbiota transplantation for recurrent Clostridium difficile infection.CMAJ. https://www.cmaj.ca/content/190/24/E746
  11. Keeping Hands Clean. (2022, June 15). Centre for Disease Control and Prevention. https://www.cdc.gov/hygiene/personal-hygiene/hands.html
  12. Life After C. diff. (2021, July 12). Centre for Disease Control and Prevention. https://www.cdc.gov/cdiff/after.html
  13. Preventing the spread of C. diff at home. (n.d.). Centre for Disease Control and Prevention. https://www.cdc.gov/hai/pdfs/cdiff/preventing-spread-of-cdiff-at-home-508.pdf
  14. Probiotics may help boost mood and cognitive function. (2023, March 22). Harvard Health Publishing. https://www.health.harvard.edu/mind-and-mood/probiotics-may-help-boost-mood-and-cognitive-function
  15. Smith, A., Musher, D., Domino, F., & Fordis, M. (n.d.). Treating and Preventing C. difficile Infections. Agency for Healthcare Research and Quality . https://effectivehealthcare.ahrq.gov/products/c-difficile-update/consumer
  16. Song, J. H., & Kim, Y. S. (2019). Recurrent Clostridium difficile Infection: Risk Factors, Treatment, and Prevention. Gut and liver, 13(1), 16–24. https://doi.org/10.5009/gnl18071
  17. Surawicz CM, McFarland LV, Greenberg RN, Rubin M, Fekety R, Mulligan ME, Garcia RJ, Brandmarker S, Bowen K, Borjal D, Elmer GW. The search for a better treatment for recurrent Clostridium difficile disease: use of high-dose vancomycin combined with Saccharomyces boulardii. Clin Infect Dis. 2000 Oct;31(4):1012-7. doi: 10.1086/318130. Epub 2000 Oct 25. PMID: 11049785.
  18. Tariq, R., Yadav, D., Tahir, M. W., Sehgal, K., Pardi, D., & Khanna, S. (2021). S136 efficacy of saccharomyces boulardii for prevention of Clostridioides Difficile Infection: A systematic review and meta-analysis. American Journal of Gastroenterology, 116(1). https://doi.org/10.14309/01.ajg.0000773016.43460.eb 
  19. Vélez, C. (2022, July 19). Preventing C. diff in and out of the hospital. Harvard Health Publishing. https://www.health.harvard.edu/blog/preventing-emc-diffem-in-and-out-of-the-hospital-202207192783
  20. WHO: How to handwash? With soap and water(2015). Youtube. Retrieved October 4th, 2023 from https://www.youtube.com/watch?app=desktop&v=3PmVJQUCm4E
  21. Your Risk of C. diff. (2022, June 27). Centre for Disease Control and Prevention. https://www.cdc.gov/cdiff/risk.html

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