What to do if exposed to Clostridioides difficile (C. diff) infection?

Management of C. difficile Exposure

For a patient concerned about C. difficile exposure who is asymptomatic and has no active infection, reassurance is appropriate with education about risk factors and preventive measures, while emphasizing that exposure alone does not require testing or treatment. 1

What to Ask: Risk Assessment

Assess Exposure Context

• Recent hospitalization or healthcare facility contact (hospitals, long-term care facilities) within the past 2-3 months 1
• Duration and type of exposure to known CDI cases 1
• Current symptoms: Specifically ask about diarrhea (≥3 unformed stools in 24 hours), abdominal pain, fever 1

Identify Risk Factors for Developing CDI

• Age >65 years 1
• Recent antibiotic use (especially clindamycin, third-generation cephalosporins, penicillins, fluoroquinolones) 1
• Proton pump inhibitor (PPI) use 1
• Comorbidities: inflammatory bowel disease, immunodeficiency/HIV, malnutrition, low albumin 1
• Recent surgery 1

What to Do: Management Algorithm

For Asymptomatic Exposed Patients

No testing or treatment is indicated for asymptomatic individuals, regardless of exposure. 1

• Do not perform C. difficile testing on asymptomatic patients, as colonization is common (0-15% in healthy adults) and does not require treatment 1
• Screening for asymptomatic carriage and placing carriers on contact precautions is not recommended 1

Preventive Measures for Exposed Patients

Hand hygiene with soap and water is the most effective prevention method because alcohol-based sanitizers do not kill C. difficile spores. 1

• Instruct patient to wash hands with soap and water (not alcohol-based sanitizers) after potential exposure, after bathroom use, and before eating 1
• Encourage showering to reduce spore burden on skin 1
• Avoid unnecessary antibiotics, particularly high-risk agents (fluoroquinolones, clindamycin, cephalosporins) 1
• Review and discontinue unnecessary PPIs if clinically appropriate 1

If Symptoms Develop

Test only if patient develops diarrhea (≥3 unformed stools in 24 hours) AND has risk factors. 1

• Initiate contact precautions immediately while awaiting test results if testing is performed 1
• Do not test formed stool or use "test of cure" after treatment 1

Special Considerations for Children

• Do not test children <12 months of age due to high rates of asymptomatic colonization 1, 2
• For children 1-2 years old, test only after excluding other causes of diarrhea 1, 2
• For children ≥2 years, test if prolonged/worsening diarrhea with risk factors or relevant exposures 1
• For C. difficile-negative children at school, standard cleaning protocols are sufficient with no special precautions needed 2

Common Pitfalls to Avoid

• Do not test asymptomatic patients "just to be sure" - this leads to unnecessary treatment of colonization 1
• Do not rely on alcohol-based hand sanitizers alone - they are ineffective against C. difficile spores 1
• Do not prescribe prophylactic antibiotics for exposure - this paradoxically increases CDI risk 1
• Do not test infants or very young children routinely, as colonization rates are extremely high (up to 50%) without clinical significance 1

Key Reassurance Points

• Exposure does not equal infection - most exposed individuals do not develop CDI 1
• Asymptomatic colonization is common and benign in healthy adults (0-15%) 1
• Simple hand hygiene with soap and water is highly effective at preventing transmission 1
• C. difficile spores are ubiquitous in healthcare environments but require disruption of normal gut flora (usually from antibiotics) to cause disease 1