Are there any risks for patients colonized with Clostridioides difficile (C. difficile) who undergo a colonoscopy?

From the Guidelines

Patients colonized with Clostridioides difficile (C. difficile) who undergo colonoscopy are at risk of developing C. difficile infection (CDI) due to the potential disruption of the normal gut microbiota and the spread of C. difficile spores during the procedure. The primary concern is the potential development of CDI following the procedure, as colonoscopy preparation and mechanical manipulation can disrupt the normal gut microbiota that helps prevent C. difficile overgrowth 1. Additionally, patients who are already colonized but asymptomatic may develop active infection following this disruption. Healthcare facilities should implement enhanced infection control measures for these patients, including thorough disinfection of endoscopy equipment with sporicidal agents, as C. difficile spores are resistant to standard disinfectants 1.

Some key points to consider include:

• The risk of CDI is particularly significant for patients with additional risk factors such as advanced age, immunosuppression, recent antibiotic use, or prior CDI episodes 1
• Clinicians should monitor these patients for symptoms of CDI (diarrhea, abdominal pain, fever) for several weeks after colonoscopy
• For high-risk colonized patients, some experts suggest considering prophylactic measures, though no standardized protocol exists
• Infection control measures for asymptomatic carriers may be effective by limiting contamination of the hospital environment and health care workers’ hands, as well as by preventing direct patient-to-patient transmission 1

It is essential to note that C. difficile colonization is not believed to be a direct independent precursor for CDI, but asymptomatic carriers may play a role in spore dissemination in the hospital, and many cases of CDI are thought to be attributable to cross-contamination from asymptomatic carriers 1. Therefore, healthcare facilities should prioritize infection control measures, including contact precautions and thorough disinfection of endoscopy equipment, to minimize the risk of CDI transmission.

From the Research

Risks for Patients Colonized with C. difficile Undergoing Colonoscopy

• There are several risks associated with patients colonized with C. difficile who undergo a colonoscopy, including the potential for transmission of the bacteria to other parts of the body or to other patients 2.
• Patients colonized with C. difficile have a higher risk of developing C. difficile infection (CDI), with a pooled prevalence of toxinogenic C. difficile colonization of 8.1% and a relative risk of 5.86 for subsequent CDIs compared to noncolonized patients 2.
• The risk of CDI for colonized patients is 21.8%, which is significantly higher than that of noncolonized patients (3.4%) 2.
• Factors that increase the risk of CDI among colonized patients include:
  • Increasing length of stay in the hospital 3
  • Exposure to multiple classes of antibiotics 3
  • Use of opioids 3
  • Presence of cirrhosis 3
• However, the use of laxatives has been associated with a lower risk of CDI among colonized patients 3.

Colonoscopy and C. difficile

• Colonoscopy has been used as a method for delivering fecal microbiota transplantation (FMT) to treat recurrent C. difficile infection, with studies showing that FMT is superior to vancomycin or fidaxomicin for treatment of recurrent CDI 4, 5.
• The delivery of donor feces via colonoscopy has been shown to be effective in treating pseudomembranous colitis, a complication of C. difficile infection 5.
• However, there is limited information on the specific risks associated with colonoscopy in patients colonized with C. difficile, and further studies are needed to fully understand the potential risks and benefits of this procedure in this patient population.