Clostridium difficile (C. diff) Infection

Definition | Aetiology | Pathophysiology | Risk Factors | Signs and Symptoms | Investigations | Management | References

Definition

Clostridium difficile (C. diff) infection is a bacterial infection that causes diarrhoea and colitis (inflammation of the colon). It commonly occurs after antibiotic use, which disrupts the normal balance of bacteria in the gut.

Aetiology

C. diff infection is caused by the Clostridium difficile bacteria. Factors that contribute to the development of this infection include:

• Recent antibiotic use, especially broad-spectrum antibiotics
• Hospitalisation or long-term care facility stays
• Older age (65 years and older)
• Weakened immune system
• Previous history of C. diff infection

Pathophysiology

The pathophysiology of C. diff infection involves:

• Disruption of the normal gut flora, usually due to antibiotic use.
• C. diff spores, which are resistant to many disinfectants and can survive in the environment for long periods, colonise the gut.
• The bacteria produce toxins (toxin A and toxin B) that cause inflammation and damage to the intestinal lining, leading to diarrhoea and colitis.

Risk Factors

• Recent antibiotic use
• Hospitalisation or residence in long-term care facilities
• Older age
• Weakened immune system
• Previous history of C. diff infection
• Use of proton pump inhibitors (PPIs)

Signs and Symptoms

The signs and symptoms of C. diff infection include:

• Watery diarrhoea (at least three bowel movements per day for two or more days)
• Abdominal cramping and pain
• Fever
• Nausea
• Loss of appetite
• Dehydration
• Severe cases can lead to pseudomembranous colitis, toxic megacolon, perforation of the colon, and sepsis

Investigations

Specific investigations to diagnose C. diff infection include:

• Stool tests: Enzyme immunoassay (EIA) for detecting C. diff toxins, PCR for C. diff toxin genes.
• Full blood count (FBC): To check for elevated white blood cell count and other markers of infection.
• Flexible sigmoidoscopy: To visualise the colon and detect pseudomembranes in severe cases.
• Imaging: Abdominal X-ray or CT scan to evaluate for complications like toxic megacolon.

Management

Primary Care Management

• Antibiotics: First-line treatment includes oral vancomycin or fidaxomicin. Metronidazole may be used for mild cases.
• Hydration: Ensuring adequate fluid intake to prevent dehydration from diarrhoea.
• Discontinuing inciting antibiotics: Stopping the antibiotic that may have triggered the infection, if possible.
• Probiotics: Consideration of probiotics to help restore normal gut flora, although evidence is mixed.

Specialist Management

• Hospitalisation: For severe cases, particularly if there are complications such as dehydration, electrolyte imbalance, or sepsis.
• Fecal microbiota transplantation (FMT): Considered for recurrent C. diff infections to restore healthy gut flora.
• Surgery: In severe cases with complications such as toxic megacolon, perforation, or refractory disease, surgical intervention may be necessary.
• Infection control measures: Strict hand hygiene, use of personal protective equipment, and environmental cleaning to prevent spread in healthcare settings.

References

1. NHS (2024) Clostridium difficile (C. diff) infection. Available at: https://www.nhs.uk/conditions/c-difficile/ (Accessed: 24 June 2024).
2. Centers for Disease Control and Prevention (2024) Clostridioides difficile Infection. Available at: https://www.cdc.gov/cdiff/index.html (Accessed: 24 June 2024).
3. World Health Organization (2024) Clostridium difficile infection. Available at: https://www.who.int/health-topics/clostridium-difficile (Accessed: 24 June 2024).
4. British Medical Journal (2024) Clostridium difficile infection: clinical features, diagnosis, and management. Available at: https://www.bmj.com/content/350/bmj.g6218 (Accessed: 24 June 2024).

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