Symptoms of Clostridioides difficile (C. diff) Infection
The primary symptoms of C. difficile infection include watery diarrhea (three or more unformed stools in 24 hours), abdominal pain, and fever, with severe cases potentially progressing to toxic megacolon, colonic perforation, and septic shock. 1
Common Clinical Manifestations
Cardinal Symptoms
- Diarrhea: Watery, sometimes bloody, occurring at least 3 times within 24 hours 1
- Abdominal pain and cramping: Often lower quadrant 1
- Fever: Temperature >38.5°C 1
Laboratory Abnormalities
- Leukocytosis (WBC >15 × 10⁹/L) 1
- Elevated serum creatinine (≥133 μM/L or ≥1.5 times premorbid level) 1
- Hypoalbuminemia (albumin <2.5 g/dL) 1
Spectrum of Disease Severity
Mild to Moderate CDI
- Diarrhea without systemic symptoms
- Minimal laboratory abnormalities
- Limited to gastrointestinal symptoms 1
Severe CDI
- Marked leukocytosis
- Significant hypoalbuminemia
- Elevated creatinine
- Fever >38.5°C 1
Fulminant CDI (1-3% of cases)
- Toxic megacolon
- Colonic perforation
- Peritonitis
- Septic shock
- Multiple organ failure
- Increased serum lactate
- Vasopressor requirements 1
Special Considerations
Recurrent CDI
- Recurrence of symptoms after initial therapy occurs in 10-30% of cases 1
- Recurrent episodes are typically less severe than initial episodes 1
- Risk of further recurrences increases to 40-65% after 1-2 previous episodes 1
Extracolonic Manifestations (Less Common)
- Reactive arthritis (particularly in knees and wrists)
- Small bowel involvement (especially with prior surgical procedures)
- Bacteremia (often polymicrobial)
- Visceral abscesses (mainly splenic) 2
Diagnostic Pitfalls
- Important: Laboratory testing alone cannot distinguish between asymptomatic colonization and clinical infection 1
- A "test of cure" is not recommended as patients may asymptomatically shed C. difficile spores for up to six weeks after successful treatment 1
- Post-infectious irritable bowel syndrome may occur in approximately 4.3% of patients, causing persistent symptoms for more than three months 1
- Systemic symptoms may result from toxins spreading into the bloodstream, not just from local inflammatory mediators 1
Clinical Impact
CDI significantly increases:
- Hospital length of stay (by approximately 16 days)
- Medical costs (by approximately $77,483)
- Mortality (3.4-fold increase) 1
- Hospital readmission rates 1
Early diagnosis and prompt treatment are crucial to reduce mortality, particularly in cases of fulminant colitis associated with the hypervirulent 027 strain of C. difficile 1.