c-diff

Clostridium difficile

This information aims to help patients, carers, and anyone who is concerned about Clostridium difficile, its diagnosis, treatment and what can be done to reduce the risks of spreading the infection.

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What is Clostridium difficile?

Clostridium difficile, also known as C. difficile or C. diff, are bacteria that are present naturally in the gut of very young children and increasingly as age increases in adults.

Clostridium difficile does not cause any problems in healthy people. However, some antibiotics that are used to treat other health conditions can interfere with the balance of 'good' bacteria in the gut. When this happens, Clostridium difficile bacteria can multiply and produce toxins (poisons), which cause illness such as diarrhoea and fever. At this point, a person is said to be infected with Clostridium difficile.

Clostridium difficile bacteria spread very easily. Despite this, Clostridium difficile infections can usually be prevented by practising good hygiene in healthcare environments, such as washing hands regularly and cleaning surfaces using disinfectants that are active against bacterial spores, like peracetic acid, hydrogen peroxide or chlorine (bleach).

You will only need treatment for a Clostridium difficile infection if you have symptoms. Sometimes, stopping the antibiotics that caused the Clostridium difficile infection is enough to clear the infection. If symptoms are more severe, you may need to take medication to clear the infection.

Most people with a Clostridium difficile infection make a full recovery. However, in rare cases, the infection can be fatal.

How do you catch it?

Clostridium difficile can be acquired naturally as the spores are present in soil and there have been suggestions that some foods can carry Clostridium difficile. The ways that people pick up Clostridium difficile are still not well understood, however there are some versions (strains) that are more linked with healthcare contacts, where large numbers of elderly people who have been treated with antibiotics are close together.

Clostridium difficile can cause illness when certain antibiotics used to treat other health conditions disturb the balance of 'good' bacteria in the gut. Its effects can range from nothing in some cases to diarrhoea of varying severity, which may resolve once antibiotic treatment is stopped, through to severe inflammation of the bowel which can sometimes be life threatening.

It is possible for the infection to spread from person to person because those suffering from Clostridium difficile-associated disease shed the germ in their faeces. When outside the body, Clostridium difficile changes into a spore which is a form that the organism takes to help it survive when conditions are harsh. Spores can survive for a very long time in the environment and can be transported on the hands of health care personnel who have direct contact with infected patients or with environmental surfaces such as floors, bedpans, toilets contaminated with Clostridium difficile. If hands are not cleaned before eating it is possible for humans to pick up spores from the environment and for them then to get into the body.

What are the symptoms of Clostridium difficile infection?

The effects of Clostridium difficile can vary from nothing to diarrhoea of varying severity and much more unusually to severe inflammation of the bowel. The symptoms of Clostridium difficile infection can include:
- mild to severe diarrhoea
- blood-stained stools
- fever
- cramps in the abdomen (tummy)

These symptoms are usually caused by inflammation (swelling and irritation) of the lining of the large intestine (bowel). In rare cases, Clostridium difficile can cause an infection of the lining of the abdomen (peritonitis), blood poisoning (septicaemia) and tears in the large intestine (perforation of the colon).

Most people who get a Clostridium difficile infection have symptoms while they are taking antibiotics. However, symptoms can appear up to 10 weeks after you finish taking antibiotics.

How do doctors diagnose Clostridium difficile infection?

Clostridium difficile infection is normally diagnosed by carrying out microbiological testing which will confirm the suspicion of Clostridium difficile toxins in the patient's faecal sample. Passing an endoscope into the patient’s colon is also used to confirm a diagnosis.

Who does it affect? Are some people more at risk?

The elderly are most at risk, over 80% of cases are reported in the over 65-age group. Children under the age of 2 years are not usually affected, although it can occur in young children.

People most vulnerable to a Clostridium difficile infection are those who:
- have been treated with broad-spectrum antibiotics (antibiotics that can treat different types of bacteria)
- have had to stay for a long time in a healthcare setting, such as a hospital
- are over 65 years old
- have a serious underlying illness or condition
- have a weakened immune system

Most infections occur in places where many people take antibiotics and are in close contact with each other, such as hospitals and nursing homes. A number of precautions can be taken to help reduce the spread of infection.

How common is it?

In recent years, the number of Clostridium difficile infections has fallen rapidly. In 2007-08, there were 55,498 cases reported across England. From December 2014 to December 2015, there were 21,449 reported cases. This is a decrease of 61% which has been achieved with strict measures in hospitals and care facilities to deal with the problem, there is still work to do to reduce this even further, as every case is one too many, which we all acknowledge.

How can it be treated?

You will only need treatment for a Clostridium difficile infection if you have symptoms. No treatment is needed if the bacteria are living harmlessly in your gut. Clostridium difficile can be treated with specific antibiotics, rather than broad spectrum antibiotics. There is a risk of relapse in 20-30% of patients and other treatments may be tried, there is now good evidence that for a small number of patients who suffer repeated infections, treatment by giving them a stool transplant from a healthy donor can restore gut bacteria and cure the infections in the majority of cases. Most cases of Clostridium difficile diarrhoea make a full recovery. However, elderly patients with other underlying conditions may have a more severe course. Occasionally, infection in these circumstances may be life threatening.

For mild or moderate symptoms of Clostridium difficile infection, it is best to stop taking the antibiotics that may have caused the infection, if this is possible. This will allow the natural 'good' bacteria to regrow in your gut. In many cases where the symptoms are mild or moderate, this is often enough to ease the symptoms and clear the infection.

If you have symptoms that are more severe, such as severe diarrhoea or colitis (swelling and irritation of the lining of the bowel), you may need to take an antibiotic that can kill Clostridium difficile bacteria. This will usually be either metronidazole or vancomycin, which should ease the symptoms within two to three days.

Possible side effects of these antibiotics are stomach ache, nausea and vomiting. Some patients treated for a Clostridium difficile infection will have a repeat of their symptoms. In rare and serious cases of Clostridium difficile infection, surgery may be needed to repair damage to the intestines (bowel), especially if there are tears in the lining of the small intestine.

What should I do to prevent the spread of Clostridium difficile to others?

If you are infected you can spread the disease to others. However, only people that are hospitalized or on antibiotics are likely to become ill. In order to reduce the chance of spreading the infection to others: it is advisable to wash hands with soap and water, especially after using the toilet and before eating; keeping surfaces in bathrooms, kitchens and other areas clean and cleaning these on a regular basis with household detergent/disinfectants. If you have had diarrhoea it is sensible to put down the toilet seat cover down, if there is one, in order to prevent aerosol contamination of the environment.

How can hospitals and care homes prevent the spread of Clostridium difficile?

Clostridium difficile bacteria can spread easily, particularly in healthcare environments, such as a hospital or care home. It may not be possible to prevent the bacteria from spreading altogether. However, a number of precautions can be taken to reduce the risk of infection.

Healthcare workers should wear disposable gloves and aprons when caring for anyone who has a Clostridium difficile infection. Whenever possible, people who are infected with Clostridium difficile should have their own room and toilet facilities to avoid passing the infection onto others.

Staff, patients and visitors should be encouraged to wash their hands regularly and thoroughly. Alcohol hand gel is not effective against Clostridium difficile spores, so the use of soap and water is essential.

Surfaces that may have come into contact with the bacteria or spores, such as toilets, the floor around toilets, bedpans and beds, should also be cleaned thoroughly with disinfectants with proven effectiveness against Clostridium difficile. Many hospitals now use peracetic acid wipes on commodes etc.

The Department of Health advises that doctors prescribe antibiotics cautiously to try to reduce the amount of broad-spectrum antibiotics being given to patients. This is to help cut down the number of people who are vulnerable to an infection.

Could I bring the infection home with me?

Clostridium difficile spores can be transmitted on hands, clothing and other objects therefore it is important to use the aprons and gloves provided for barrier nursing, to take extra care there are a number of things you can do:

Wash your hands before and after contact with the patient, and before handling food.

Do not use the same towel or face cloth as someone who has a healthcare associated infection.

Wash laundry from an infected patient at 60 degrees for at least ten minutes. There are antibacterial detergents available for more delicate fabrics, - check the label or manufacturer for effectiveness against MRSA and Clostridium difficile at low temperatures.

If anyone has presented signs of diarrhoea or vomiting clear up soiling accidents straightaway, wash with hot soapy water and disinfect with a chlorine disinfectant or bleach.

Disinfect door and toilet handles, taps and the toilet seat after use and disinfect the toilet bowl frequently.

Is there guidance on effective hand-washing?

Effective hand washing is very important to avoid spreading Clostridium difficile, as it is easy for patients to become reinfected.

Alcohol gel is not effective at eradicating the spores therefore washing with soap and water is important. Keep fingernails clipped and short and avoid wearing rings and jewellery.

Ensure hands are washed before and after patient contact, after visiting the lavatory and before eating. Patients, visitors and all health workers need to follow this strict hand hygiene regime for everyone's protection. In an outbreak situation, the Infection Control Team may introduce special measures for staff, patients and visitors to follow.

The animation below shows how to wash hands effectively:

- Wet hands
- Apply liquid soap
- Rub hands palm to palm
- Rub right palm over back of left hand
- And left palm over back of right hand
- Palm to palm fingers interlaced
- Back of fingers to opposing palm with fingers interlocked
- Rotational rubbing of right thumb clasped in left palm
- Rotational rubbing of left thumb clasped in right palm
- Rotational rubbing backwards and forwards with clasped fingers in palms (to clean around and under fingernails)
- Rinse
- Dry with paper towels

If you are visiting a person in a healthcare environment who has diarrhoea or a stomach upset, try to avoid taking any children under the age of 12 with you. You should also:
- wash your hands with soap and water when entering and leaving ward areas
- observe visiting hours and all visiting guidelines
- avoid healthcare environments if you are feeling unwell or have recently had diarrhoea

If you are worried and think you may have symptoms of Clostridium difficile then seek immediate medical advice.

References:

NHS choices: Clostridium difficile - last reviewed 03/02/2016, next review due 03/02/2018

Clostridium difficile: guidance, data and analysis - Public Health England 1 July 2014

Clostridium difficile infection: guidance on management and treatment - Public Health England, June 2013- This document supersedes relevant sections of Clostridium difficile infection: How to deal with the problem (below)

Clostridium dificile infection: How to deal with the problem - Department of Health and Health Protection Agency December 2008

Clinical Trials: Probiotics for the Prevention of Antibiotics Associated Diarrhoea and Clostridium Difficile Associated Diarrhoea

Probiotics for treatment of Clostridium difficile-associated colitis in adults. Pillai A, Nelson RL, Published Online: July 16, 2008

National Institute for Health and Clinical Excellence: Prevention and control of healthcare-associated infections quality improvement guide [PH36]:- Published date: November 2011

Infection: prevention and control of healthcare-associated infections in primary and community care - NICE Clinical guidelines, CG139 - Issued: March 2012

National Institute for Health and Care Excellence (NICE): Infection Control Quality Standard [QS61]: - Published date: April 2014

National Institute for Health and Care Excellence (NICE) quality standard [QS113]: Healthcare-associated infections - Published date: February 2016

NICE Accredited EPIC 3 guidelines

Further help and information

UK Clostridium difficile Support

Content written 18/02/2016
Review due 18/02/2019

(c) MRSA Action UK 2016

email: info@mrsaactionuk.net

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