5 things to know about C. diff

Clostridioides difficile infection (C. diff), primarily caused by improperly prescribed antibiotics or exposure to contaminated surfaces, is one of the most frequent health care-associated infections in the United States. Symptoms range from mild diarrhea to fulminant colitis and death.

There have been several advances in C. diff treatment and recurrence prevention, and effective management requires an understanding of diagnostic assays and therapeutic options, as well as appropriate measures to prevent infection.

To help physicians across all specialties better understand this increasingly common infection, the AOA has sponsored a three-module CME course which provides updated recommendations regarding the proper procedures for prevention, diagnosis and treatment of C. diff.

Each module is free for members and nonmembers, and the course, which is eligible for 1.5 category 1-B AOA CME credits, takes about two hours to complete.

• Module I focuses on the epidemiology of C. diff infection was well as identifying patients at risk of community-acquired C. diff.
• Module II reviews data that informed the current guidelines and the clinical implications of the guidelines for the treatment of C. diff and its recurrence.
• Module III contains an in-depth review of treatment options for C. diff infection.

Carman Ciervo, DO, a family physician and the chief physician executive of Jefferson Health in New Jersey, joined Krishna Rao, MD, an infectious diseases specialist and an assistant professor in the University of Michigan Medical School, to present these modules.

In this edited Q&A, Dr. Ciervo shares a few things he says all physicians should know about C. diff.

What are some of the most common causes of C. diff?

You see it in particular when patients are placed on certain antibiotics that put them at higher risk, like clindamycin. Often this will come from a dental appointment. Dentists tend to use that antibiotic to cover for bacteria in the mouth. Depending on a patient’s bowel flora to begin with or how long they’re on the clindamycin, they can then develop C. diff.

There are also people who are on antibiotics for other reasons for prolonged periods of time. Some communities have greater propensity to develop it than others, so you’re seeing it there as well.

Regardless, when somebody’s presenting and complaining of significant diarrhea, the C. diff antigen is one of the things that you’ve got to test for.

Why has C. diff become more commonplace?

It has become more common recently with the greater utilization of broad-spectrum antibiotics. You can also see it in hospitals where you don’t have good antibiotic stewardship. If an infectious diseases (ID) department isn’t controlling the types of antibiotics that are being used for certain infections, you’ll run into problems.

For example, if somebody comes in with community-acquired pneumonia, rather than having them on an IV azithromycin or semi-synthetic penicillin, which would cover most of what needs to be covered, somebody’s being put on a broad-spectrum antibiotic.

With those stronger antibiotics, you’re promoting C. diff rates. Different hospitals have different C. Diff rates, and as the hospital goes, so does the community.

At my hospital, you can’t write certain antibiotics without an ID consult, which really controls that craziness that occurs around what I would call using a nuclear spike missile to kill a bacteria you could kill with a fly swatter.

What is the current recommended treatment for C. diff?

If it’s a patient’s first C. diff episode, it could be Flagyl (metronidazole) and oral vancomycin, or another oral antibiotic, fidaxomicin. If it’s a second episode, you’re going to treat it for a longer period of time, and start with fidaxomicin.

When it comes to a point where someone is having multiple bouts and it’s just not stopping, and it’s affecting their life and overall health due to lost weight and body mass, then you’ve got to think about a fecal microbiota transplant. That’s something a primary care physician would certainly refer to a gastrointestinal or ID specialist.

It’s better not to start the problem to begin with.

Why is it important for physicians to know all they can about C. diff?

It’s just about doing the right thing. There needs to be greater awareness of the broad spectrum antibiotics that carry a greater risk for a C. diff infection.

Physicians should know that some of these antibiotics are frequently prescribed in the fields of dentistry and podiatry. Once their patients get C. diff, you can be sure you’re going to have to treat it.

Every time you prescribe an antibiotic, you want to think about whether you really need to do it. Every time you prescribe antibiotics, there is a risk.

How does COVID-19 play a role in the importance of C. diff awareness?

During the pandemic, you may not be seeing patients in person as much since so many visits are via telehealth. As a result, you may be erring on the side of prescribing a stronger antibiotic. That tendency is even more of a reason to have awareness of C. diff.

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