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Clostridioides difficile (C. difficile)

What is Clostridioides difficile?

Clostridioides difficile (C. difficile) is a bacterial infection that can cause diarrhea. Symptoms can range from mild diarrheal illness to severe colitis and can result in death. C. difficile causes almost half a million illnesses per year. Most of these illnesses occur in adults and in people who have recent exposures to medical care and antibiotics. However, anyone, including children, can become ill from C. difficile under the right circumstances. The burden of C. difficile among pediatric patients appears to be much higher in community settings compared to hospital settings. There are two types of C. difficile bacteria, toxigenic and nontoxigenic. Only toxigenic C. difficile bacteria can cause symptoms. A person must also have an imbalance in their normal, healthy gut flora, which allows C. difficile to flourish and cause inflammation and damage to the gut. Normal, healthy gut flora can be disturbed for many reasons, but a major cause is previous exposure to antibiotics. 

Signs and symptoms

  • Watery diarrhea (typically at least three bowel movements per day for at least 24 hours)
  • Fever
  • Loss of appetite
  • Nausea
  • Abdominal pain and tenderness
  • Rarely, severe illness can cause high fever, bloated abdomen and occasional blood in the stool
  • Children aged 5 years and younger, especially infants, frequently have no symptoms

Incubation period

  • Variable; symptoms typically develop five days after exposure to an antibiotic. However, symptoms can occur anywhere between one day and 10 weeks or more. 
  • Some people will experience a recurrent infection which may occur after the initial episode of diarrhea has been treated and resolved. People who experience a relapse of diarrhea or have fever, chills, and/or abdominal pain should contact their doctor. 
  • Asymptomatic infants can carry the bacteria for an unknown period of time without becoming ill.

Contagious period and spread

  • C. difficile is spread through the fecal→oral route. Transmission can occur when a person comes into contact with feces of someone who is infected or colonized. Not everyone who ingests C. difficile bacteria will become ill. 
  • People who are ill with C. difficile can shed the bacteria into the environment, causing surfaces to become contaminated. C. difficile can live on environmental surfaces for several months.
  • Improper hand hygiene is a major contributor to the spread of C. difficile.
  • C. difficile can spread as long as the bacteria are in the stool. People are most likely to shed the bacteria when they have active diarrhea. The more frequent and uncontrolled the diarrhea is, the more likely they are to shed the bacteria. 
  • People who are being treated for C. difficile are less infectious than those who are not on treatment. A person is generally considered contagious until 48 hours after the last episode of diarrhea. However, it is not fully understood how long a person may continue to shed bacteria after diarrhea stops. 

Public health reporting requirements

  • C. difficile infections are laboratory reportable to the state health department for residents of the Denver metropolitan area (Adams, Arapahoe, Denver, Douglas, and Jefferson counties). Single cases outside of these five counties are not reportable.
  • The school nurse or child care health consultant should be consulted for specific concerns, or consultation with state or local public health personnel is available.
  • If other children or staff from the same classroom are ill with diarrhea, refer them to their health care providers and contact public health as soon as possible as this could be an outbreak, and all outbreaks are reportable to the state or local health departments. There are many causes of diarrhea; C. difficile does not typically cause outbreaks in educational settings. 

Control of spread

  • Meticulous hand hygiene for staff and students/children: Handwashing with soap and water is the most effective method to prevent the spread of C. difficile. 
  • Proper hand hygiene with soap and water is required, especially after using the bathroom, after changing a diaper, prior to preparing and eating meals, and anytime hands are visibly soiled.
  • Alcohol-based hand sanitizer does not kill C. difficile spores.
  • Glove use is required if contact with stool could occur, and hand hygiene must be performed with soap and water immediately following removal of gloves.

Environmental cleaning

  • Gloves must be worn when cleaning areas contaminated with stool, and hand hygiene with soap and water are required immediately after glove removal.
  • CDC recommends meticulous cleaning followed by disinfection using hypochlorite (bleach) based germicides of potentially contaminated surfaces and items.
  • Surfaces that may be contaminated with stool (diaper changing areas and bathrooms) should be: 
    • Cleaned with detergent and rinsed water to remove dirt and debris.
    • Disinfected by applying either (1) an EPA registered disinfectant from List K labeled effective against C. difficile spores according to label instructions for disinfection, OR (2) household bleach (follow the mixing and application instructions for disinfection on the specific bottle of bleach used). The recommendation is to achieve 5,000 ppm available hypochlorite (which is equivalent to 1:10 dilution of 5.25% bleach).
      ** Read labels carefully to ensure the bleach or other disinfectant product is applied correctly. Bleach or disinfectant products must be mixed and applied appropriately to ensure disinfection. **
  • Soiled linen and clothing
    • Clothing, towels, and blankets that are soiled or potentially contaminated can be laundered in the hottest water safe for the item with normal detergent. Chlorine bleach should be used if safe for the item being laundered. Dry on high heat. Items with visible stool contamination should be rinsed well before washing.
    • Items that are contaminated with high hazard bodily fluids, such as stool, should be laundered separately. 
    • Dry cleaning is not as effective as standard washing at killing spores. This option should only be used for items that cannot be machine washed.

Treatment

Typically antibiotics are prescribed for an initial episode, depending on disease severity and other factors. Some providers may choose to not treat an episode of C. difficile under certain circumstances. People with multiple recurrences or severe illness may be treated surgically. 

Exclusion

  • Exclude students/children who have been diagnosed with C. difficile infection and who have active diarrhea until at least 48 hours after their diarrhea has resolved, without the use of anti-diarrheal medications. 
  • In certain cases people might experience recurring or ongoing diarrheal illness with C. difficile infection. In these circumstances, the benefits and risks of having the student/child attend school or group care should be considered. 
  • Factors that should be considered in the decision to allow children with recurring/ongoing diarrheal illness with C. difficile infection include: 
    • If the diarrhea is controlled, meaning the student or child is not having accidents and is able to go to the bathroom when needed, or if the student or child is in diapers, the diarrhea must be able to be contained in the diaper. 
    • If the student/child is receiving treatment for the infection.
  • CDPHE and your local public health department are available for consultation as needed.

Role of teachers, caregivers, and family

  • Bloody diarrhea may be a sign of C. difficile but many other pathogens can also cause this. Any bloody diarrhea should trigger a medical evaluation.
  • For known cases of C. difficile, ensure that the advice of the health care provider and public health are followed to prevent transmission.
  • Educate and reeducate about the importance of meticulous hand hygiene using soap and water. C. difficile spores are not killed by alcohol-based hand sanitizers.

Resource

Prevent C. diff (CDC)