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Clostridium difficile infection: Prevention and control

Carolyn Gould, MD, MSCR
L Clifford McDonald, MD
Section Editor
Stephen B Calderwood, MD
Deputy Editor
Elinor L Baron, MD, DTMH


Clostridium difficile is the most frequent infectious cause of healthcare-associated diarrhea and is a significant cause of morbidity and mortality among hospitalized patients [1]. Studies suggest that both the incidence and severity of C. difficile infection (CDI) have increased, associated with substantial short- and long-term attributable costs [2]. In the United States, the incidence of CDI appears to be plateauing at historic high levels, while in the United Kingdom the incidence has decreased following the introduction of nationwide control interventions [3,4]. Most CDI cases in the United States are associated with inpatient or outpatient contact with a healthcare setting [5,6]. Evidence supports the potential for C. difficile transmission in outpatient settings [7]. (See "Clostridium difficile in adults: Epidemiology, microbiology, and pathophysiology", section on 'Nosocomial infection' and "Clostridium difficile infection in children: Microbiology, pathogenesis, and epidemiology", section on 'Epidemiology'.)

Development of CDI usually requires two events: disruption of the fecal microbiota (typically via exposure to antibiotics) and acquisition of the organism via the fecal-oral route. C. difficile may be shed into the environment by individuals who are infected or colonized. C. difficile colonizes the colon of less than 5 percent of healthy adults [8]; high rates of colonization may occur among hospitalized adults, nursing home residents, and healthy infants [9-11]. C. difficile spores can be transmitted between patients via environmental surfaces and contaminated hands of healthcare personnel. Thus, efforts to prevent and control C. difficile must focus on two goals: reducing patient susceptibility to CDI and preventing organism transmission.

Prevention of C. difficile transmission is especially challenging because the organism forms spores, which can persist on environmental surfaces for months and are resistant to commonly used hospital cleaning agents and alcohol-based hand gels [12]. Thus, prevention and control of CDI require a number of interventions. This was illustrated in a report of a C. difficile hypervirulent strain outbreak; the outbreak was successfully controlled with introduction of successive interventions with the guidance of ongoing surveillance [13]. Successful prevention has also been demonstrated by statewide programs and national initiatives emphasizing public reporting, antibiotic stewardship, and infection control measures [5,14].

Issues related to CDI prevention and control will be reviewed here. The pathophysiology, epidemiology, clinical manifestations, and treatment of CDI are discussed separately. (See related topics.)


Infection control — Improved infection control and antibiotic stewardship are critical interventions for reducing the incidence of C. difficile infection in healthcare settings [15]. A detailed practice recommendation for prevention of C. difficile infection in acute-care hospital settings from the Society for Healthcare Epidemiology of America and the Infectious Diseases Society of America is available [16]. The recommendations are summarized briefly here.


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Literature review current through: Sep 2016. | This topic last updated: Apr 26, 2016.
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