For UK healthcare professionals

Identify &
test for CDI

Clostridioides difficile infection (CDI) remains a considerable public health challenge with significant mortality and hospital costs1-5

The 2020/2021 hospital-onset CDI case fatality rate in England was 23.4% (all-cause mortality) – the highest rate recorded since 2013/20145

CDI may be FORGOTTEN but it is not GONE…

About CDI

Clostridioides difficile is a bacteria that can
cause infectious, life-threatening diarrhoea2,6

What are the symptoms of
C. difficile infection (CDI)?6,7

  • Watery diarrhoea several times a day

  • A high temperature

  • A loss of appetite

  • Feeling sick

  • Stomach pain

  • Signs of dehydration

CDI commonly occurs due to the disruption of the normal colonic microbiome – usually as a result of broad-spectrum antibiotic use, but infection can also follow chemotherapy or immunosuppressant drugs8

Which of your patients may be at risk of CDI?

CDI normally develops in people who are already vulnerable6,9,10

  • Older age (>65 years)6,9

  • Recent antibiotic exposure6,9,10

  • Prolonged stay in hospital/care home6

  • People with IBD10

  • Use of nasogastric tube9

  • Immunocompromised6,9

  • Those using PPIs6

CDI, C. difficile infection; IBD, Inflammatory bowel disease; PPI, Proton pump inhibitor.

Impact of CDI

Fatality rates

CDI remains a considerable public health challenge
with significant mortality and hospital costs1-4

The 2020/2021 overall CDI CFR in England was 14.9%
(all-cause mortality)5

23.4%

Hospital-onset CDI in England
The 2020/2021 hospital-onset CFR in England was 23.4% (4,254 cases, all-cause mortality) – the highest rate recorded since 2013/20145

There were 12,503 cases of CDI reported in England in 2020/20215

Clinical impact

The clinical burden of CDI on patients is significant8

Complications of CDI can include:8,11,12

  • Colitis8
    Inflammation
    of the colon
  • Toxic megacolon11
    Life-threatening
    expansion of the colon
  • Paralytic ileus12
    Paralysis of the intestines
  • Pseudomembranous colitis8
    A manifestation
    of severe disease
  • Perforated colon8
    Leading to peritonitis
    and sepsis

Economic impact

CDI is associated with a significant financial burden2

CDI significantly increases the length of hospital stay and hospital costs including:2

  • CDI control measures13

  • Isolation rooms – impacting bed availability13

  • Environmental decontamination13

Recurrent CDI requires repeated and prolonged treatment,
further increasing length of stay and total costs2

Mean total length of hospital stay2 Mean total costs2
First EPISODE of CDI
17 days
(95% CI 12–21)
£12,710
(95% CI 9652–15769)
First RECURRENCE
33 days
(95% CI 19–46)
£31,121
(95% CI 19792–42447)

A retrospective matched cohort study of adult and paediatric inpatients (n=45) to compare costs and resource use of patients with a first episode of CDI with those with a recurrent episode of CDI.2

Recurrence

CDI recurs in approximately 1 in 5 patients12

Recurrent CDI usually occurs within a few weeks after completion of initial C. difficile treatment, but can be delayed for up to 12 weeks12,14

The risk of recurrence increases
with each episode:14,15

Risk

  • After 1st episode
    20%
    to 25%
  • After 2nd episode
    40%
    to 45%
  • After 3 or more episodes
    60%
    to 65%

Recurrent CDI is associated with:

  • Serious clinical complications, including sepsis and colectomy4
  • Significantly increased risk of death within 6 months16

CDI, C. difficile infection; CFR, Case fatality rate; CI, Confidence interval.

Identifying CDI

Do not wait to test for CDI17

If a patient has unexplained diarrhoea then it is necessary to test for CDI

Collect stools from symptomatic patient as early as possible to minimise C. difficile transmission risk

Do NOT wait to initiate sampling/testing, as this delay may increase the risk of C. difficile transmission

Department of Health recommends
a 2-step testing system for CDI17

Step 1.

GDH EIA (or NAAT/PCR)

If above is positive
Step 2.

Sensitive toxin EIA test (or a cytotoxin assay)*

*Note: a cytotoxin assay (the reference method) yields slower results and this needs to be taken
into account when making management and infection control decisions17

Interpretation of a 2-step C. difficile testing algorithm17

Step 3. Interpreting test results The following actions should be taken depending on the test result:
Result of 2-test algorithm** Interpretation Include in mandatory reporting†
GDH EIA (or NAAT) positive, toxin EIA positive CDI is likely to be present Yes
GDH EIA (or NAAT) positive, toxin EIA negative C. difficile could be present, so may have transmission potential. Patient could be potential C. difficile excretor. No, but may be suitable for local reporting
GDH EIA (or NAAT) negative, toxin EIA negative C. difficile or CDI is very unlikely to be present, so may have transmission potential. Patient could have other potential pathogens. No
It must be remembered that no test or combination of tests is infallible and the clinical condition of the patient should always be taken into consideration when making management and treatment choices.17

**A cytotoxin assay may be considered as an alternative to a sensitive toxin EIA, but it yields slower results and this will need to be taken into account in making decisions about infection control.17

†Unless a repeat sample within 28 days. Please refer to the Mandatory Surveillance Protocol for full case definition and further information.17

Where there’s any doubt  Suspect. test. act.

GDH, glutamate dehydrogenase; EIA, enzyme immunoassay; NAAT, nucleic acid amplification test; PCR, polymerase chain reaction test.

Prevention of CDI

During an infection, C. difficile
can produce:

Toxins (TcdA and TcdB)

which contribute to tissue damage
and disease symptoms18,19

Spores

which are responsible for the persistence
and recurrence of C. difficile in patients18

C. difficile spores are extremely difficult to eradicate – they can
tolerate extreme environmental conditions, surviving on surfaces
for months, leading to new or recurrent infections20

Spores can withstand
destruction by:20,21

  • Disinfectants

  • Drying

  • Heating

  • Gastric acid

  • Antibacterial soaps

  • Hand gel

Clostridioides difficile is
infectious, with
transmission
via the faecal-oral route22,23

  • Spores in diarrhoea contaminate the environment
    C. difficile spores lie dormant in the environment
    Ingestion of spores
  • Disease symptoms: diarrhoea
    Faecal-oral route of transmission
    Disruption of normal enteric flora – C. difficile colonisation
  • C. difficile toxins cause intestinal damage
    Growth of C. difficile in the colon
    Risk factors

Prevention of CDI

There are 2 core strategies for preventing CDI:14


Antibiotic stewardship, by optimising the use of antibiotics and minimising disruption of the normal colonic microbiota – use of narrow-spectrum
antibiotics if possible14
Infection prevention, by blocking the spread and acquisition of the
C. difficile organism14

Follow Department of Health Guideline SIGHT in
case of suspected CDI13

Department of Health
Guideline – SIGHT13

S Suspect that a case may be infective where there is no clear alternative cause for diarrhoea
I Isolate the patient and consult with the infection control team (ICT) while determining the cause of the diarrhoea
G Gloves and aprons must be used for all contacts with the patient and their environment
H Hand washing with soap and water should be carried out before and after each contact with the patient and the patient’s environment
T Test the stool for toxin [using a 2-step testing system], sending a specimen immediately

Find out more
Where there’s any doubt  Suspect. test. act.

GDH, C. difficile infection.

References