C. diff (Clostridioides difficile) Infection

What is C. diff (Clostridioides difficile)?

C. diff is a nickname for a bacterium whose full name is Clostridioides difficile (klos-TRID-e-OY-dees dif-uh-SEEL). This bacterium can infect your colon (large intestine), causing diarrhea and other uncomfortable symptoms.

Bacterial infections in your colon are common, and most aren’t serious. But C. diff infection can be more aggressive and harmful to your colon. C. difficile releases toxins that damage the cells in your intestinal lining. This causes inflammation in your intestinal lining and colon (colitis). Whether you have symptoms, and how severe they are, will depend on the extent of the damage from these toxins. When it’s severe, it can be life-threatening.

Clostridioides difficile is a newer name for Clostridium difficile.

How common is Clostridioides difficile infection?

C. diff infection (CDI) is a global health concern, although the exact rates of infection worldwide are unknown. In the U.S., 500,000 infections cause 15,000 deaths each year.

What are the symptoms of C. diff infection?

The most common symptom, and usually the first to appear, is watery diarrhea. A mild infection will cause diarrhea at least three times a day, often with some abdominal cramping.

As C. diff infection becomes more severe, diarrhea increases. It may occur as much as 10 to 15 times a day. You may notice traces of blood in your poop or other symptoms, like:

• Persistent abdominal pain
• Swollen, distended abdomen
• Nausea and vomiting
• Loss of appetite
• Fever
• Rapid heart rate

C. diff symptoms may resemble food poisoning or stomach flu at first. If you’re taking antibiotics, it’s possible to mistake C. diff diarrhea for a normal side effect of medication.

But sometimes, C. diff infections can occur without diarrhea.

What does C. diff poop look like?

C. diff diarrhea is typically mushy or porridge-like, but not completely liquid. Sometimes, it has a green tint, though other bacterial infections can also cause this. Occasionally, it contains blood, mucus or pus.

What does C. diff poop smell like?

Many people notice a distinctive odor with C. diff diarrhea. They describe it as unusually strong and oddly sweet. This smell may be because C. diff increases the levels of bile acids in your poop.

What causes C. diff infection?

A healthy immune system normally protects your gut from C. diff infection by keeping C. diff levels under control. If they grow out of control, it’s because something has affected the balance between “helpful” bacteria and “unhelpful” bacteria. Everyone has bacteria in their intestines. Helpful types of living bacteria help to keep other bacteria, like C. diff, in check.

The most common cause of C. diff infection is taking antibiotics. Using them upsets the balance between helpful and unhelpful bacteria in your gut microbiome, allowing C. diff to dominate and overgrow.

How does C. diff spread?

C. difficile reproduces by releasing spores. These spores can also spread on skin, surfaces and other items. This means if you touch something with the spores on it, and then eat or touch your mouth, you can get C.diff that way.

Why is C. diff so contagious?

Outside your body, C. diff turns into spores that are very hard to kill, both inside and outside of your intestines. They’re resistant to heat, acid and many antibiotics and disinfectants. They can also survive for months on surfaces.

Researchers estimate about 5% of the population has C. difficile in their colon without signs or symptoms of infection. You can have C. diff under control, but still carry and spread it to others.

Can you be around someone with C. diff?

Yes, you can be around someone with C. diff if you take precautions. To minimize the risk of spreading the infection, you should:

• Wash your hands frequently
• Avoid touching your nose, mouth and eyes
• Disinfect surfaces
• Use gloves, a face mask, a gown and other protective equipment

Who is at higher risk for developing C. diff?

Medical conditions that may reduce your defenses against C. diff infection include:

• Inflammatory bowel disease (IBD). Chronic inflammatory bowel diseases, including Crohn’s disease and ulcerative colitis, wear down your intestines over time. They destroy the mucosa in your intestinal lining, which affects your gut immunity.
• Weakened immune system. You may have reduced immunity in general, not just in your gut, if you have an immunodeficiency disorder or another chronic disease that affects your immune system — like cancer, HIV, kidney disease or diabetes. The same is true if you take immunosuppressants.

Other risk factors associated with C. diff infection include:

• Age. Being over 65 increases your risk of C. diff infection. This may be due to lower immunity, taking multiple medications or living in a hospital or personal care home. Infants also get C. diff more often.
• Hospitalization or correctional facilities. C. diff spreads easily in places that contain many people living together. Spores can live for months on common surfaces and spread from person to person through shared spaces like restrooms.

Sometimes, it isn’t clear what allowed C. diff to take over. While many factors can affect your gut immunity, it’s important to know that infection can occur even if you don’t have any known risk factors.

What complications can occur with C. diff infection?

Complications can occur with more severe infections. How severe your infection becomes will depend on several factors, including the strain of the bacteria you have and how strong your immune system is.

People who have more risk factors for getting a C. diff infection in the first place may be more at risk of a severe infection. They may also have repeat infections, which cause more damage over time.

Common complications include:

• Recurrent infection. As many as 20% of people will experience a relapse within two to eight weeks of completing treatment. As many as 40% will have another relapse after that.
• Dehydration and electrolyte losses. Losing fluids and electrolytes faster than you can replace them has dangerous side effects, including low blood volume, low blood pressure and, in severe cases, kidney failure.
• Pseudomembranous colitis. A severe type of colitis that can cause thick, scab-like plaques to form on the lining of your colon.

As toxic damage in your colon progresses, you may have further complications, including:

• Fluid leakage. Your colon may begin to leak fluids into your abdominal cavity (ascites), causing it to swell. You may also lose proteins from your colon, leading to low albumin — which can cause swelling, fatigue and other symptoms.
• Reactive arthritis. Severe infection may trigger reactive arthritis, which can cause inflammation, swelling and pain in your joints and other places in your body.
• Toxic megacolon. Toxic megacolon is rare but serious. It happens when swelling from inflammation is so severe that it disables your colon. It can eventually lead to sepsis.

How is C. diff infection diagnosed?

If your healthcare provider suspects C. diff infection based on your symptoms, they’ll take a sample of your poop and send it to a lab. The lab will test it for C. diff toxins.

If you test positive, your healthcare provider may conduct further tests to find out how severe the infection is. These may include blood tests and imaging tests that look inside your colon.

What is the treatment for C. diff infection?

Treatment for C. diff infection is based on how severe it is. If you developed a C. diff infection while taking antibiotics, your provider might begin by simply stopping those medications.

For some people, this is enough. Their natural gut immunity returns and overcomes the infection. If this doesn’t happen, your provider will prescribe antibiotics that can stop C. diff.

Antibiotics to treat C. diff include:

• Metronidazole
• Vancomycin
• Fidaxomicin

If you have a mild infection, you’ll take the prescription home with you. Most people will start improving in a few days. If your infection is more severe, you might need to stay in the hospital.

In the hospital, your provider might give you antibiotics through an IV, along with fluids to prevent dehydration. In some cases, they might deliver medications directly into your colon as an enema.

Complicated C. diff infection

If you have severe complications, you might need intensive care. In rare cases, providers recommend emergency surgery to remove the source of the infection in your colon. This is called colectomy.

If you’ve recovered but you continue to have repeat infections after treatment, your options are:

• Repeat antibiotic therapy. Your provider may give you a different drug, or a longer prescription for the same drug. After antibiotics, your provider may recommend that you take probiotics to help restore your gut bacteria.
• Fecal microbiota transplant. When repeat antibiotic therapy fails, fecal transplantation has proved highly effective in preventing recurrent C. diff infection. Fecal transplantation involves transferring a poop sample from a healthy donor into a diseased colon. The sample will restore balance to your gut microbiome.

What precautions can help to prevent C. diff. from spreading?

Healthcare providers take special precautions when dealing with C. diff infection to help prevent the spread of this highly contagious disease. You can follow their example to help keep others safe:

• Isolation. If you have the infection, it’s best to stay isolated in your own room. Anyone entering the room to care for you should wear disposable gloves and remove them after they leave. You should also avoid sharing toilets since the infection spreads through your poop. If you must share a toilet, disinfect the handle, seat and surrounding area with a bleach-based cleaner after use.
• Handwashing. Frequent handwashing with soap and warm water is especially important with C. diff, since hand sanitizer doesn’t affect it. It’s important for everyone you interact with.
• Disinfection. Many common disinfectants don’t work against C. diff, but products containing bleach can. It’s important to disinfect any surfaces you’ve touched, especially in the bathroom.
• Taking antibiotics as prescribed. Don’t take other people’s antibiotics or save antibiotics for later.

What can I expect if I have C. diff?

Most C. diff infections are mild and go away with treatment. But the circumstances that cause C. diff infection sometimes allow it to spread very quickly. C. diff infection can be sudden and severe.

If you have risk factors that make you more vulnerable to C. diff infection, you may be more likely to have a more severe infection or have repeat infections and need more extensive treatment.

Does C. diff. ever go away on its own?

It can go away on its own if your healthy gut bacteria return to defeat it. This is more likely if your intestinal flora is normally strong and you don’t have any long-term health factors that usually weaken it.

If you got the infection because you were taking antibiotics, it might go away after you stop taking them. But don’t wait too long for this to happen. If you don’t feel better in a few days, contact your provider.

Once you have C. diff, do you always have it?

It’s likely that some of the bacteria will survive after treatment, but you can have some without having an infection. As long as helpful gut bacteria also survive, they should help to control C. difficile.

If you have repeat infections, it’s because these other bacteria haven’t been restored yet. Repeat infections may be the original one relapsing, but they aren’t always. Sometimes, they’re new infections.

Will I have long-term problems after C. diff. infection?

The most common long-term problem is ongoing or repeat infection with C. difficile. This happens when your colon is having trouble recovering completely. Your colon may be slower to recover if:

• You had a more severe infection that did more damage to your intestinal lining
• You had to take antibiotics for a long time or had to take them for C. diff after taking others
• You have a long-term health condition that affects your intestines or immune system
• You’re older than 65

More rarely, some people develop autoimmune disorders after a severe infection. This means that their immune systems continue to act as though they have an infection even when they don’t anymore.

Autoimmune disorders that start after C. diff infection include post-infectious IBS (irritable bowel syndrome) and reactive arthritis.

What questions should I ask my provider about C. diff infection?

You might want to ask:

• How serious is my infection?
• Am I at risk of complications?
• How will I know when C. diff is getting better?
• When should I call you? When should I go to the ER?
• Do I need a referral to a gastroenterologist?
• What are my options for treating repeat infections?