Skip to main content
Log in

The Importance of Colonization with Clostridium difficile on Infection and Transmission

  • Healthcare Associated Infections (G Bearman and D Morgan, Section Editors)
  • Published:
Current Infectious Disease Reports Aims and scope Submit manuscript

Abstract

Clostridium difficile infections (CDI) are the most common cause of healthcare-associated infections (HAI) in the USA, accounting for 12 % of all HAIs [1]. Reasons for such an increase are unknown but may relate to antibiotic use and evolution of a new, pathogenic strain, NAP1/BI/027. The Centers for Disease Control and Prevention (CDC) identifies C. difficile as one of only three organisms to be assigned a designation of an “urgent” threat level. Asymptomatic colonization with C. difficile is much more common than symptomatic CDI and has been documented to contribute to new cases of CDI. Despite this knowledge, approaches to managing and preventing transmission from asymptomatically colonized patients are lacking. Enhanced cleaning, avoidance of unnecessary antimicrobials, and use of gowns and gloves for patients with CDI are the cornerstone of C. difficile management in patients with known disease. Infection control interventions to prevent transmission from asymptomatically colonized patients have not been determined.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1

Similar content being viewed by others

References

  1. Magill SS, Edwards JR, Bamberg W, et al. Multistate point-prevalence survey of health care-associated infections. N Engl J Med. 2014;370(13):1198–208.

    Article  CAS  PubMed  Google Scholar 

  2. Reveles KR, Lee GC, Boyd NK, Frei CR. The rise in Clostridium difficile infection incidence among hospitalized adults in the United States: 2001–2010. Am J Infect Control. 2014;42:1028–32.

    Article  PubMed  Google Scholar 

  3. Lucado J, Gould C, Elixhauser A. Clostridium difficile infections (CDI) in hospital stays, 2009. Healthcare Cost and Utilization Project (HCUP) statistical brief #124. 2012. http://www.hcup-us.ahrq.gov/reports/statbriefs/sb124.jsp. Accessed 07 Jul 2015.

  4. Lessa FC, Mu Y, Bamberg WM, et al. Burden of Clostridium difficile infection in the United States. N Engl J Med. 2015;372(9):825–34.

    Article  CAS  PubMed  Google Scholar 

  5. Centers for Disease Control and Prevention. Methicillin-resistant Staphylococcus aureus (MRSA) infections: MRSA tracking. 2014. http://www.cdc.gov/mrsa/tracking/index.html. Accessed 23 Jun 2015.

  6. Kallen A. Uncharted territory: what really works for CRE prevention. Orlando: Society for Healthcare Epidemiology of America (SHEA); 2015.

    Google Scholar 

  7. Centers for Disease Control and Prevention (CDC). Emerging Infections Program - Healthcare-associated Infections Program: Multi-site Gram Negative Bacilli Surveillance Initiative (MuGSI). 2014. http://www.cdc.gov/hai/eip/mugsi.html. Accessed 29 Jun 2015.

  8. Bagdasarian N, Rao K, Malani PN. Diagnosis and treatment of Clostridium difficile in adults: a systematic review. JAMA. 2015;313:398–408.

    Article  CAS  PubMed  Google Scholar 

  9. Zacharioudakis IM, Zervou FN, Pliakos EE, Ziakas PD, Mylonakis E. Colonization with toxinogenic C. difficile upon hospital admission, and risk of infection: a systematic review and meta-analysis. Am J Gastroenterol. 2015;110(3):381–90.

    Article  PubMed  Google Scholar 

  10. Bartlett JG. Antibiotic-associated pseudomembranous colitis. Rev Infect Dis. 1979;1(3):530–9.

    Article  CAS  PubMed  Google Scholar 

  11. McDonald LC, Coignard B, Dubberke E, Song X, Horan T, Kutty PK. Recommendations for surveillance of Clostridium difficile-associated disease. Infect Control. 2007;28(2):140–5.

    Google Scholar 

  12. Clabots CR, Johnson S, Olson MM, Peterson LR, Gerding DN. Acquisition of Clostridium difficile by hospitalized patients: evidence for colonized new admissions as a source of infection. J Infect Dis. 1992;166(3):561–7.

    Article  CAS  PubMed  Google Scholar 

  13. Samore MH, DeGirolami PC, Tlucko A, Lichtenberg DA, Melvin ZA, Karchmer AW. Clostridium difficile colonization and diarrhea at a tertiary care hospital. Clin Infect Dis. 1994;18(2):181–7.

    Article  CAS  PubMed  Google Scholar 

  14. Loo VG, Bourgault A, Poirier L, et al. Host and pathogen factors for Clostridium difficile infection and colonization. N Engl J Med. 2011;365(10):1693–703.

    Article  CAS  PubMed  Google Scholar 

  15. Alasmari F, Seiler SM, Hink T, Burnham CA, Dubberke ER. Prevalence and risk factors for asymptomatic Clostridium difficile carriage. Clin Infect Dis. 2014;59(2):216–22.

    Article  PubMed Central  PubMed  Google Scholar 

  16. Didelot X, Eyre DW, Cule M, et al. Microevolutionary analysis of Clostridium difficile genomes to investigate transmission. Genome Biol. 2012;13(12):R118.

    Article  PubMed Central  CAS  PubMed  Google Scholar 

  17. Dubberke ER, Han Z, Bobo L, et al. Impact of clinical symptoms on interpretation of diagnostic assays for Clostridium difficile infections. J Clin Microbiol. 2011;49:2887–93.

    Article  PubMed Central  PubMed  Google Scholar 

  18. Burnham CA, Carroll KC. Diagnosis of Clostridium difficile infection: an ongoing conundrum for clinicians and for clinical laboratories. Clin Microbiol Rev. 2013;26:604–30.

    Article  PubMed Central  CAS  PubMed  Google Scholar 

  19. Johnson S, Louie TJ, Gerding DN, et al. Vancomycin, metronidazole, or tolevamer for Clostridium difficile infection: results from two multinational, randomized, controlled trials. Clin Infect Dis. 2014;59(3):345–54.

    Article  CAS  PubMed  Google Scholar 

  20. Louie TJ, Miller MA, Mullane KM, et al. Fidaxomicin versus vancomycin for Clostridium difficile infection. N Engl J Med. 2011;364(5):422–31.

    Article  CAS  PubMed  Google Scholar 

  21. van Nood E, Vrieze A, Nieuwdorp M, et al. Duodenal infusion of donor feces for recurrent Clostridium difficile. N Engl J Med. 2013;368(5):407–15.

    Article  CAS  PubMed  Google Scholar 

  22. Dubberke ER, Carling P, Carrico R, et al. Strategies to prevent Clostridium difficile infections in acute care hospitals: 2014 update. Infect Control Hosp Epidemiol. 2014;35 Suppl 2:S48–65.

    PubMed  Google Scholar 

  23. Shim JK, Johnson S, Samore MH, Bliss DZ, Gerding DN. Primary symptomless colonisation by Clostridium difficile and decreased risk of subsequent diarrhoea. Lancet. 1998;351(9103):633–6.

    Article  CAS  PubMed  Google Scholar 

  24. Kyne L, Warny M, Qamar A, Kelly CP. Asymptomatic carriage of Clostridium difficile and serum levels of IgG antibody against toxin A. N Engl J Med. 2000;342(6):390–7.

    Article  CAS  PubMed  Google Scholar 

  25. Kyne L, Warny M, Qamar A, Kelly CP. Association between antibody response to toxin A and protection against recurrent Clostridium difficile diarrhoea. Lancet. 2001;357(9251):189–93.

    Article  CAS  PubMed  Google Scholar 

  26. Drekonja DM, Amundson WH, DeCarolis DD, Kuskowski MA, Lederle FA, Johnson JR. Antimicrobial use and risk for recurrent Clostridium difficile infection. Am J Med. 2011;124(11):1081. e1–7.

    Article  PubMed  Google Scholar 

  27. Curry SR, Muto CA, Schlackman JL, Pasculle AW, Shutt KA, Marsh JW, et al. Use of multilocus variable number of tandem repeats analysis genotyping to determine the role of asymptomatic carriers in Clostridium difficile transmission. Clin Infect Dis. 2013;57(8):1094–102.

    Article  PubMed Central  PubMed  Google Scholar 

  28. McDonald LC. Editorial commentary: looking to the future: vertical vs horizontal prevention of Clostridium difficile infections. Clin Infect Dis. 2013;57(8):1103–5.

    Article  PubMed  Google Scholar 

  29. Eyre DW, Cule ML, Wilson DJ, et al. Diverse sources of C. difficile infection identified on whole-genome sequencing. N Engl J Med. 2013;369(13):1195–205.

    Article  CAS  PubMed  Google Scholar 

  30. Eyre DW, Griffiths D, Vaughan A, et al. Asymptomatic Clostridium difficile colonisation and onward transmission. PLoS One. 2013;8(11):e78445.

    Article  PubMed Central  CAS  PubMed  Google Scholar 

  31. Barbut F, Petit J. Epidemiology of Clostridium difficile‐associated infections. Clin Microbiol Infect. 2001;7(8):405–10.

    Article  CAS  PubMed  Google Scholar 

  32. Kim KH, Fekety R, Batts DH, Brown D, Cudmore M, Silva Jr J, et al. Isolation of Clostridium difficile from the environment and contacts of patients with antibiotic-associated colitis. J Infect Dis. 1981;143(1):42–50.

    Article  CAS  PubMed  Google Scholar 

  33. McFarland LV, Mulligan ME, Kwok RY, Stamm WE. Nosocomial acquisition of Clostridium difficile infection. N Engl J Med. 1989;320(4):204–10.

    Article  CAS  PubMed  Google Scholar 

  34. Riggs MM, Sethi AK, Zabarsky TF, Eckstein EC, Jump RL, Donskey CJ. Asymptomatic carriers are a potential source for transmission of epidemic and nonepidemic Clostridium difficile strains among long-term care facility residents. Clin Infect Dis. 2007;45(8):992–8.

    Article  PubMed  Google Scholar 

  35. Dubberke ER, Reske KA, Noble-Wang J, et al. Prevalence of Clostridium difficile environmental contamination and strain variability in multiple health care facilities. Am J Infect Control. 2007;35(5):315–8.

    Article  PubMed  Google Scholar 

  36. Guerrero D, Becker J, Eckstein E, Kundrapu S, Deshpande A, Sethi A, et al. Asymptomatic carriage of toxigenic Clostridium difficile by hospitalized patients. J Hosp Infect. 2013;85(2):155–8.

    Article  CAS  PubMed  Google Scholar 

  37. Carmeli Y, Venkataraman L, DeGirolami PC, Lichtenberg DA, Karchmer AW, Samore MH. Stool colonization of healthcare workers with selected resistant bacteria. Infect Control Hosp Epidemiol. 1998;19(1):38–40.

    Article  CAS  PubMed  Google Scholar 

  38. Säll O, Johansson K, Norén T. Low colonization rates of Clostridium difficile among patients and healthcare workers at Örebro University Hospital in Sweden. APMIS. 2015;123(3):240–4.

    Article  PubMed  Google Scholar 

  39. Friedman ND, Pollard J, Stupart D, et al. Prevalence of Clostridium difficile colonization among healthcare workers. BMC Infect Dis. 2013;13:459.

    Article  PubMed Central  PubMed  Google Scholar 

  40. Viscidi R, Willey S, Bartlett JG. Isolation rates and toxigenic potential of Clostridium difficile isolates from various patient populations. Gastroenterology. 1981;81(1):5–9.

    CAS  PubMed  Google Scholar 

  41. Ozaki E, Kato H, Kita H, et al. Clostridium difficile colonization in healthy adults: transient colonization and correlation with enterococcal colonization. J Med Microbiol. 2004;53(Pt 2):167–72.

    Article  PubMed  Google Scholar 

  42. Sethi AK, Al-Nassir WN, Nerandzic MM, Bobulsky GS, Donskey CJ. Persistence of skin contamination and environmental shedding of Clostridium difficile during and after treatment of C. difficile infection. Infect Control. 2010;31(1):21–7.

    Google Scholar 

  43. Siegel JD, Rhinehart E, Jackson M, Chiarello L. Health Care Infection Control Practices Advisory Committee. 2007 Guideline for isolation precautions: preventing transmission of infectious agents in health care settings. Am J Infect Control. 2007;35(10 Suppl 2):S65–164.

    Article  PubMed  Google Scholar 

  44. Morgan DJ, Murthy R, Munoz-Price LS, et al. Reconsidering contact precautions for endemic methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant Enterococcus (VRE). Infect Control Hosp Epidemiol. In Press.

  45. Lanzas C, Dubberke ER. Effectiveness of screening hospital admissions to detect asymptomatic carriers of Clostridium difficile: a modeling evaluation. Infect Control. 2014;35(8):1043–50.

    Google Scholar 

  46. Donskey CJ, Kundrapu S, Deshpande A. Colonization versus carriage of Clostridium difficile. Infect Dis Clin North Am. 2015;29(1):13–28.

    Article  PubMed  Google Scholar 

  47. Gerding DN, Meyer T, Lee C, et al. Administration of spores of nontoxigenic Clostridium difficile strain M3 for prevention of recurrent C. difficile infection: a randomized clinical trial. JAMA. 2015;313(17):1719–27.

    Article  PubMed  Google Scholar 

  48. Orenstein R, Aronhalt KC, McManus JE, Fedraw LA. A targeted strategy to wipe out Clostridium difficile. Infect Control. 2011;32(11):1137–9.

    Google Scholar 

Download references

Compliance with Ethics Guidelines

Conflict of Interest

Carey-Ann Burnham reports grants from Cepheid, bioMerieux and Accelerate Diagnostics. Erik Dubberke reports grants and personal fees from Sanofi Pasteur and Merck. Surbhi Leekha received honorarium from the American Hospital Association/Health Research and Educational trust. Daniel Morgan reports personal fees from Welch Allyn, grants from VA HSRD, other from IDSA, ASM, and SHEA for expenses to organize or present at national meetings and personal fees from 3M.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by the author.

Author information

Authors and Affiliations

Authors

Corresponding author

Correspondence to Daniel J. Morgan.

Additional information

This article is part of the Topical Collection on Healthcare Associated Infections

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Morgan, D.J., Leekha, S., Croft, L. et al. The Importance of Colonization with Clostridium difficile on Infection and Transmission. Curr Infect Dis Rep 17, 43 (2015). https://doi.org/10.1007/s11908-015-0499-0

Download citation

  • Published:

  • DOI: https://doi.org/10.1007/s11908-015-0499-0

Keywords

Navigation