Clostridium Difficile
Infection

Clostridium Difficile Infection: Overview

Alternative Names: C. diff, Clostridium Difficile Colitis, Clostridium Difficile Infection, C. difficile infection

A Clostridium Difficile Infection (CDI) involves the overgrowth of C. diff bacteria in the digestive tract.  These bacteria release toxins that attack the lining of the intestines.

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There are over 1,000 different species of bacteria in the human digestive tract, the majority of which are harmless or even beneficial.  The good bacteria normally coexist with a smaller number (ideally 15% or less) of harmful bacteria and prevent them from taking over.  When this natural balance is upset and there is an overgrowth of harmful bacteria, health problems can arise.  One of the most regular offenders is the species Clostridium difficile (C. difficile).

Incidence; Contributing Risk Factors

CDI occurs primarily in hospitalized patients and among older adults in long-term care facilities.

Long-term antibiotic use increases risk of C. diff infection.  Antibiotics – especially broad-spectrum antibiotics or combinations of antibiotics – can kill off many of the good bacteria that keep C. diff growth under control.

Other risk factors that predispose a person to C. diff infection include previous C. diff infection, gastrointestinal surgery, preexisting intestinal disease, a weak immune system, chemotherapy drugs used to treat cancer, old age, kidney disease, and proton-pump inhibitors (PPIs such as Nexium, Prevacid, or Prilosec) which reduce the amount of stomach acid present.

Signs and Symptoms

Bad bacteria release toxins, which lead to a variety of symptoms, including:

Diagnosis and Tests

C. difficile testing is often carried out when a patient reports frequent watery stools, abdominal pain, fever, and/or nausea lasting 3 or more days, during or following a course of antibiotics, or following recent gastrointestinal surgery.

The main diagnostic tool is stool testing for specific toxins.  Various tests are available, including Clostridium difficile Culture, C. difficile Cytotoxin Assay, Glutamate Dehydrogenase Enzyme Immunoassay, and Real-time Polymerase Chain Reaction (PCR) assay.

Other testing includes a complete blood count (CBC) which may indicate an increase in the number of white cells in the blood, usually caused by an infection.  Testing electrolyte levels, including serum creatinine, may indicate electrolyte imbalance in severe cases.  Testing albumin levels may indicate hypoalbuminemia in severe cases.  Testing serum lactate levels may indicate elevated lactate levels (≥5 mmol/L) in severe cases.

A colonoscopy may also be used to confirm the diagnosis and determine severity.  It may indicate the presence of raised, yellowish-white, 2-10mm plaques on the intestinal mucosa.

An abdominal CT scan may be used to look for CDI complications such as sepsis.

Treatment and Prevention

Some patients with mild disease recover without therapy.  However, diarrhea lasting for several weeks, even when mild, should be treated.

WARNING: Always wait at least 24 hours before starting to use anti-diarrhea medication.  This gives the body more time to remove toxins from the intestinal tract.  Taking anti-diarrhea medicine too soon can prevent this detoxification process.  If you suspect a C. diff infection, talk to your doctor before starting anti-diarrhea medication.

As distasteful as it sounds, fecal microorganism transplantation (fecal enemas or infusion of donor feces through a tube passed through the nose) has been reported to repopulate the colonic flora and treat recurring CDI.

C. diff usually spreads via the fecal-oral route and is able to live for a long time on dry surfaces.  For this reason, proper hygiene – such as washing hands after using the bathroom and before meals – is the most important form of prevention.

Prognosis; Complications

A C. diff infection can range in severity from mild to life-threatening.  Relapse occurs in 20-27% of patients.  Once a patient has suffered a relapse, the risk for a second relapse rises to 45%.  When this occurs, stronger antibiotics need to be used.

This infection can, in rare cases, lead to perforation of the intestines, which is a medical emergency.

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C. Difficile Infection:

Risk factors for Clostridium Difficile Infection:

Medical Procedures

Appendix removed after/appendix removed before age 20

It is now thought by many doctors that the appendix is a "safe house" or cultivation center for the normal, beneficial bacteria that our gut needs.  When a serious infection strips away the good bacteria, the appendix can then release good bacteria back into the large intestine to repopulate it.

A study involving 252 patients at Winthrop University Hospital found that patients without an appendix were more than twice as likely to have a recurrence of C. difficile.  Recurrence in individuals with their appendix intact occurred in 18% of cases; recurrence in those without their appendix occurred in 45% of cases.

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Recommendations for Clostridium Difficile Infection:

Digestion

Drug

Antibiotics

Even though this disease can be caused by long-term antibiotic use, and mild cases can often be treated by simply stopping antibiotic use, the main treatment for severe C. diff is, ironically, a 10- to 14-day course of antibiotics.  The antibiotics most commonly used are Flagyl (metronidazole), Dificid (fidaxomicin), or Vancocin (vancomycin).  Symptoms usually start to improve within 3 days.

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