Carol Raye’s devastating Clostridioides difficile (C. difficile) experience started with what she thought was a stomach bug after a dental visit. She took the antibiotics prescribed by her dentist and thought a weekend of rest would make her feel better. Soon, she was debilitated by the severe diarrhea from a C. difficile infection that left her weak, confused and barely able to get out of bed. Fortunately, she made it to the doctor after nearly a month of illness after an acquaintance realized she was in trouble. She spent the next six months fighting the infection and regaining strength. Now, ten years later, she is still living with ongoing effects, and, like me, wants to prevent C. difficile infection so that others don’t have to share her experience.
C. difficile is one of the most common health care-associated infections causing more than 450,000 infections and 12,000 deaths per year in the U.S. Providers in health systems, hospitals, and other facilities have made great progress in leveling rates of health care-associated C. difficile, but now we are seeing a troubling new trend as community-associated cases are on the rise. With this shift, we must expand vigilance to prescribers in community settings like primary care, dental, and home care workers.
The reasons for the shift to community-associated infections are not yet fully understood. One reason may be that some chronic conditions previously managed in a hospital setting can now be managed on an outpatient basis, meaning fewer hospital days. Some strains of C. difficile are more commonly associated with community spread, but the source of these strains is unknown. Emerging research from outside the U.S. suggests that agriculture, soil or water may be a source, however more research is needed. What we do know is that health care providers can change their behaviors to fight the threat of C. difficile for their patients. The germs that cause C. difficile infections can live in the body without causing harm until antibiotics throw the microbiome into disarray by eliminating protective microbes and allowing C. difficile to proliferate and cause dangerous symptoms.
Health care prescribers should focus on using the right antibiotics for the proper amount of time anytime they prescribe these medications for patients. New guidance from the Society for Healthcare Epidemiology of America’s Strategies to Prevent Clostridioides difficile Infections in Acute Care Hospitals: 2022 Update urges providers to use the most targeted antibiotics available and to limit the use of broad-spectrum antibiotics most commonly associated with C. difficile infection, like clindamycin, cephalosporins and fluoroquinolones. Prescribers should also be vigilant about prescribing antibiotics only when they are clinically indicated since any use of antibiotics can predispose patients to C. difficile infection.
Health care providers should also educate patients about when they should consult a physician if they experience distress after taking antibiotics. C. difficile infections can progress quickly in some patients, so catching it early is critical. Patients with three or more instances of watery diarrhea per day or new and unexplained diarrhea should be screened for C. difficile infection. As rates of community spread increase, providers must be on heightened alert for the early symptoms of infection because of its insidious and long-term effects.
After multiple recurrences, Carol ultimately received a fecal microbiota transplant (FMT) and began the long road to recovery. In addition to the physical effects of C. difficile, including ongoing sensitivities that restrict her diet, Carol experienced isolation, embarrassment and fear of spreading the infection that affected her mental health and social life. Fortunately, Carol has shared her story and become a patient advocate through the Peggy Lillis Foundation to fight for better policy and education for health care providers and patients. She is passionate about making C. difficile a reportable condition for health care facilities, urging development of new medications and educating other patients and health care providers about her experience.
We all must remember Carol’s experience and channel her energy to prevent the harmful effects of C. difficile on our patients.
Larry K. Kociolek is an infectious disease physician.