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Background
Clostridium difficile (C. difficile) is a bacterium that causes diarrhea and more serious intestinal conditions such as colitis. It is the most frequently identified cause of hospital-acquired diarrheal infection. Disease may occur when the normal intestinal flora is altered, allowing the organism to flourish in the intestinal tract and produce a toxin that causes a watery diarrhea. Since antibiotics alter the normal levels of “good” bacteria found in the intestines and colon, antibiotic treatment is the greatest risk factor for patients, especially when clindamycin, cephalosporins, and penicillins are used – though virtually every antibiotic has been implicated. Repeated enemas, prolonged nasogastric tube insertion and gastrointestinal tract surgery also increase the risk of infection.
Clostridium difficile is a bacterium that forms an endospore or a dormant state with increased resistance when conditions in the human or animal body or the environment become unfavorable for it to survive in its vegetative (actively growing) state. In the endospore stage, C. difficile spores will not be destroyed on environmental surfaces by disinfectants.
Hands of personnel, as well as a variety of environmental sites within institutions, have been found to be contaminated with C. difficile, which can persist in spore form for many months.1 It can be part of the normal intestinal flora in as many as 50 percent of children under age 2, and less frequently in individuals over age 2. It also occurs ubiquitously in the environment in spore form.
The combination of the presence of C. difficile in hospitals and healthcare settings and the number of people receiving antibiotics in these settings can lead to frequent outbreaks.
Symptoms and disease process
Symptoms include watery diarrhea (at least three bowel movements per day for two or more days), fever, loss of appetite, nausea and abdominal pain and tenderness.
Primary routes of transmission
Healthy people usually are not susceptible to C. difficile disease. Patients requiring prolonged use of antibiotics and the elderly are at greater risk of acquiring this disease, and can be affected even by low doses. Since the bacteria are found in feces, people can become infected if they touch items or surfaces that are contaminated with feces and then touch their mouth or mucous membranes. Healthcare workers can spread the bacteria to other patients or contaminate surfaces through hand contact.
Control
Evidence for contamination of the hospital environment by C. difficile is compelling and aggressive cleaning and disinfection is effective in reducing the number of C. difficile positive cultures in the environment.
The vegetative form of C. difficile, such as might be found on fecally-contaminated surfaces, may be killed by EPA-registered hospital-use disinfectant products or simply exposure to air. Some EPA-registered disinfectants have C. difficile label claims for the vegetative form. However, it is important to note that disinfectants or disinfectant-detergents intended for use on environmental surfaces are not effective against the spore form of C. difficile under practical-use conditions, regardless of the class of disinfectant or the manufacturer of the product.
Stringent handwashing practices are absolutely essential for minimizing the transmission of the disease via the hands. Hand hygiene is crucial in the interruption of the potential disease transmission from person to person. While alcohol-based hand hygiene products are effective in promoting hand hygiene compliance, most are not effective against the spores of C. difficile. In the case of a C. difficile outbreak, traditional handwashing with soap and water for the mechanical removal and rinsing of spores from the hands is recommended.
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References
1Gerding DN, Johnson S, Peterson LR, Mulligan ME, Siolva J Jr. 1995. Clostridium difficile-associated diarrhea and colitis. Infect Control Hosp Epidemiol. 16:459-477.
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