Clostridium difficile (C. difficile): Questions and Answers

Clostridium difficile or C. difficile is a bacterium that causes diarrhea and more serious intestinal conditions such as colitis. It is the most common cause of infectious diarrhea in hospitalized patients in the industrialized world. It is also one of the most common infections in hospitals and long-term care facilities.

The use of antibiotics increases the chances of developing C. difficile diarrhea. Treatment with antibiotics alters the normal levels of good bacteria found in the intestines and colon. When there are fewer of these good bacteria, C. difficile can thrive and produce toxins that can cause an infection. The combination of the presence of C. difficile in hospitals and health care settings and the number of people receiving antibiotics in these settings can lead to frequent outbreaks.

In these settings, C. difficile infections can be limited through careful use of antibiotics and the use of routine infection control measures. The Public Health Agency of Canada has developed these infection control guidelines for use by the provinces, territories and health care organizations.

• How do people get C. difficile?
• What can be done to prevent its spread?
• What are the symptoms of C. difficile infection?
• Is C. difficile fatal?
• How can C. difficile be treated?
• Why are we hearing so much about C. difficile now?
• What is the Public Health Agency of Canada doing about this situation?
• What will the Agency do with this study?
• What sort of things will the study examine?
• What hospitals are participating in the study?
• Have the recent issues with C. difficile prompted this new study?
• What puts a person at risk of C. difficile?
• What is the Public Health Agency of Canada going to do about the use of proton pump inhibitors?

How do people get C. difficile?

Healthy people are not usually vulnerable to C. difficile. People who have other illnesses or conditions requiring prolonged use of antibiotics and the elderly are at greater risk of infection. C. difficile bacteria are found in feces. People can become infected if they touch items or surfaces that are contaminated with feces and then touch their mouths or mucous membranes. Health care workers can spread the bacteria to other patients or contaminate surfaces through hand contact.

What can be done to prevent its spread?

The Public Health Agency of Canada publishes infection control guidelines for use by the provinces, territories and health care organizations. As with any infectious disease, frequent hand washing is one of the best defenses.

What are the symptoms of C. difficile infection?

Symptoms include:

• watery diarrhea (at least three bowel movements per day for two or more days)
• fever
• loss of appetite
• nausea
• abdominal pain/tenderness

Is C. difficile fatal?

In rare cases, C. difficile can be fatal. More commonly, the infection causes diarrhea. Diarrhea can lead to serious complications, including dehydration.

How can C. difficile be treated?

For people with mild symptoms, no treatment is required. The symptoms usually clear up once the patient stops using antibiotics. For severe cases, medication and surgical interventions may be required.

Why are we hearing so much about C. difficile now?

A recent study in Quebec indicates that a more resilient strain of the bacteria may be present in hospitals in the province. The study found that C. difficile was indirectly responsible for 108 deaths during a six-month period. Many of these patients were elderly and other factors contributed to their deaths but younger patients have also been affected.

What is the Public Health Agency of Canada doing about this situation?

The Public Health Agency of Canada is helping to examine the most recent outbreaks in Quebec. Through the Canadian Nosocomial Infection Surveillance Program, the Agency will also start a six-month surveillance study in teaching hospitals across the country. The study will run from November 1, 2004 to April 30, 2005.

In January 2005, the Agency will also survey all hospitals in Canada to get a better understanding of their infection prevention and control practices for C. difficile.

What will the Agency do with this study?

Information collected through the study will be used to update the Public Health Agency of Canada's infection control guidelines.

What sort of things will the study examine?

The study will focus on what happens to patients who have C. difficile-associated diarrhea (CDAD). It will look closely at the most serious results of the infection including dehydration, admissions to intensive care units, surgeries required to stop the infection and the number of deaths associated with the infection.

The Agency's National Microbiology Lab will also study the bacteria to see if there is a way to differentiate between severe and mild cases of infection. It will also look at whether there is a new strain of the bacteria that makes people much sicker than the other strains. If researchers identify a new strain, the Lab will also try to determine where it is in Canada.

What hospitals are participating in the study?

Have the recent issues with C. difficile prompted this new study?

Plans were made for heightened surveillance of C. difficile at the annual meeting of hospital infection control officers in September 2004.

What puts a person at risk of C. difficile?

Risk factors include treatment with antibiotics, increasing age and cytotoxic chemotherapy. A study published in the Canadian Medical Association Journal (July 6, 2004), found that the risk of C. difficile diarrhea was higher among patients using proton pump inhibitors. The authors found that patients receiving antibiotics and proton pump inhibitors were more than twice as likely as those receiving only antibiotics to contract the infection. Other researchers have also previously reported this association.

Proton pump inhibitors are a family of drugs (brand names include, for example, Losec ® and Prevacid ®) used to treat stomach ulcers. The proton pump inhibitors work by completely blocking the production of stomach acid. They do this by inhibiting or shutting down a system in the stomach known as the proton pump. The reduction of normal gastric acids is associated with other infectious diarrhea, including travellers' diarrhea and cholera so it is possible that the use of proton pump inhibitors is also a risk factor for C. difficile associated diarrhea.

It is important to remember that it is the combination of antibiotics and proton pump inhibitors that may increase the risk of C. difficile infection. Concerned individuals who are taking these drugs should talk to their health care provider.

What is the Public Health Agency of Canada going to do about the use of proton pump inhibitors?

According to recently published studies, reduction of the use of proton pump inhibitors may be another strategy to reduce C. difficile infections in health care settings. The Public Health Agency of Canada is working closely with Health Canada on this issue. Health Canada regulates these drugs and is consulting manufacturers in Canada to develop a strategy to reduce the risk of C. difficile infections.