Clostridioides (Clostridium) difficile Infection

Clostridioides (Clostridium) difficile Infection


  • Hand hygiene (soap if visibly soiled). Also applies to those caring for patients with diarrhea.
  • Cleaning of shared equipment, including stethoscopes.
  • Adherence to contact precautions.
  • Use antibiotics wisely!
  • Patient with a history of C. difficile requiring antibiotic therapy for another indication(s): prophylactic metronidazole or vancomycin is not routinely recommended.


  • Taking the shape of the receptacle, or corresponding to Bristol stool chart types 6–7

    • NOTE: formed stool typically NOT processed, unless concern for ileus
  • Greater than or equal to 3 unformed stools in 24 or fewer consecutive hours

  • Cannot be explained for any other reason

Ensure patient is NOT receiving:

  • Laxatives for the past 24-48 hours

If you have questions about whether or not to send a stool sample, please contact the Medical Microbiologist for clarification

Do NOT test stool from asymptomatic patients.

  • C. difficile toxin positive without current symptoms is NOT considered C. difficile disease
  • ~10% of pts will test positive within one week of hospitalization, some studies suggest up to 50% of patients will be colonized after >4 weeks in hospital
  • Colonization rates are ~10% in LTC

Repeat testing for cure is NOT indicated

Stat testing is available. PCR testing in the setting of a negative screen with high clinical suspicion is also available.

More Information

  1. Perras C et al. 2011 Vancomycin or Metronidazole for Treatment of Clostridium difficile Infection: Clinical and Economic Analyses [Internet]. Ottawa: Canadian Agency for Drugs and Technologies in Health; (Technology report; no. 136).
  2. Janarthanan S et al. 2012 Clostridium difficile -Associated Diarrhea and Proton Pump Inhibitor Therapy: A Meta-Analysis. Am J Gastroenterol 107:1001.
  3. Kwok CS et al. 2012 Risk of Clostridium difficile Infection with Acid Suppressing Drugs and Antibiotics: Meta-Analysis. Am J Gastroenterol 107:1011.
  4. McFarland LV et al. 2002 Breaking the Cycle: Treatment Strategies for 163 Cases of Recurrent Clostridium difficile Disease. Am J of Gastroenterol 97(7):1769.
  5. Johnston BC et al. 2012 Probiotics for the prevention of Clostridium difficile-associated diarrhea: a systematic review and meta-analysis. Ann Intern Med 157:878.
  6. Zar FA et al. 2007 A comparison of vancomycin and metronidazole for the treatment of Clostridium difficile-associated diarrhea, stratified by disease severity. Clinical Infectious Diseases 45:302.
  7. Surawicz CM et al. 2013 Guidelines for Diagnosis, Treatment, and Prevention of Clostridium difficile Infections. Am J Gastroenterol 108:478.
  8. Clabots CR et al. 1992 Acquisition of Clostridium difficile by hospitalized patients: evidence for colonized new admissions as a source of infection. J Infect Dis 166(3):561.
  9. Loo, V., Davis, I., Embil, J., Evans, G., Hota, S., Lee, C., Lee, T., Longtin, Y., Louie, T., Moayyedi, P., Poutanen, S., Simor, A., Steiner, T., Thampi, N. and Valiquette, L. (2018). Association of Medical Microbiology and Infectious Disease Canada treatment practice guidelines for Clostridium difficile infection. Official Journal of the Association of Medical Microbiology and Infectious Disease Canada, 3(2), pp.71-92.
  10. Brown, C., Manis, M., Bohm, N. and Curry, S. (2018). Oral Vancomycin for Secondary Prophylaxis of Clostridium difficile Infection. Annals of Pharmacotherapy, 53(4), pp.396-401.
  11. Crook, D., Walker, A., Kean, Y., Weiss, K., Cornely, O., Miller, M., Esposito, R., Louie, T., Stoesser, N., Young, B., Angus, B., Gorbach, S. and Peto, T. (2012). Fidaxomicin Versus Vancomycin for Clostridium difficile Infection: Meta-analysis of Pivotal Randomized Controlled Trials. Clinical Infectious Diseases, 55(suppl_2), pp.S93-S103.
  12. Debast, S., Bauer, M. and Kuijper, E. (2014). European Society of Clinical Microbiology and Infectious Diseases: Update of the Treatment Guidance Document for Clostridium difficile Infection. Clinical Microbiology and Infection, 20, pp.1-26.
  13. Carignan, A., Poulin, S., Martin, P., Labbé, A., Valiquette, L., Al-Bachari, H., Montpetit, L. and Pépin, J. (2016). Efficacy of Secondary Prophylaxis With Vancomycin for Preventing Recurrent Clostridium difficile Infections. American Journal of Gastroenterology, 111(12), pp.1834-1840.
  14. Crowther, G., Chilton, C., Longshaw, C., Todhunter, S., Ewin, D., Vernon, J., Karas, A. and Wilcox, M. (2016). Efficacy of vancomycin extended-dosing regimens for treatment of simulated Clostridium difficile infection within an in vitro human gut model. Journal of Antimicrobial Chemotherapy, 71(4), pp.986-991.
  15. Hota, S., Sales, V., Tomlinson, G., Salpeter, M., McGeer, A., Coburn, B., Guttman, D., Low, D. and Poutanen, S. (2016). Oral Vancomycin Followed by Fecal Transplantation Versus Tapering Oral Vancomycin Treatment for Recurrent Clostridium difficile Infection: An Open-Label, Randomized Controlled Trial. Clinical Infectious Diseases, 64(3), pp.265-271.
  16. R Kaki, A Brooks, C Main, P Jayaratne, D Mertz. Does Extending Clostridium Difficile Treatment In Patients Who Are Receiving Concomitant Antibiotics Reduce The Rate Of Relapse?. The Internet Journal of Infectious Diseases. 2016 Volume 15 Number 1.
  17. Murphy, M., Patatanian, E. and Gales, M. (2018). Extended duration vancomycin in recurrent Clostridium difficile infection: a systematic review. Therapeutic Advances in Infectious Disease, 5(6), pp.111-119.
  18. Van Hise, N., Bryant, A., Hennessey, E., Crannage, A., Khoury, J. and Manian, F. (2016). Efficacy of Oral Vancomycin in Preventing RecurrentClostridium difficileInfection in Patients Treated With Systemic Antimicrobial Agents. Clinical Infectious Diseases, 63(5), pp.651-653.
  19. Gerding, D. (2018). Is pulsed dosing the answer to treatment of Clostridium difficile infection?. The Lancet Infectious Diseases, 18(3), pp.231-233.
  20. Guery, B., Menichetti, F., Anttila, V., Adomakoh, N., Aguado, J., Bisnauthsing, K., Georgopali, A., Goldenberg, S., Karas, A., Kazeem, G., Longshaw, C., Palacios-Fabrega, J., Cornely, O. and Vehreschild, M. (2018). Extended-pulsed fidaxomicin versus vancomycin for Clostridium difficile infection in patients 60 years and older (EXTEND): a randomised, controlled, open-label, phase 3b/4 trial. The Lancet Infectious Diseases, 18(3), pp.296-307.
  21. Soriano, M., Danziger, L., Gerding, D. and Johnson, S. (2014). Novel Fidaxomicin Treatment Regimens for Patients With Multiple Clostridium difficile Infection Recurrences That Are Refractory to Standard Therapies. Open Forum Infectious Diseases, 1(2), pp.ofu069-ofu069.
  22. Johnson, S., Louie, T., Gerding, D., Cornely, O., Chasan-Taber, S., Fitts, D., Gelone, S., Broom, C. and Davidson, D. (2014). Vancomycin, Metronidazole, or Tolevamer for Clostridium difficile Infection: Results From Two Multinational, Randomized, Controlled Trials. Clinical Infectious Diseases, 59(3), pp.345-354.
  23. Stevens, V., Nelson, R., Schwab-Daugherty, E., Khader, K., Jones, M., Brown, K., Greene, T., Croft, L., Neuhauser, M., Glassman, P., Goetz, M., Samore, M. and Rubin, M. (2017). Comparative Effectiveness of Vancomycin and Metronidazole for the Prevention of Recurrence and Death in Patients With Clostridium difficile Infection. JAMA Internal Medicine, 177(4), p.546.
  24. Vardakas, K., Polyzos, K., Patouni, K., Rafailidis, P., Samonis, G. and Falagas, M. (2012). Treatment failure and recurrence of Clostridium difficile infection following treatment with vancomycin or metronidazole: a systematic review of the evidence. International Journal of Antimicrobial Agents, 40(1), pp.1-8.
  25. Blaabjerg, S., Artzi, D. and Aabenhus, R. (2017). Probiotics for the Prevention of Antibiotic-Associated Diarrhea in Outpatients—A Systematic Review and Meta-Analysis. Antibiotics, 6(4), p.21.
  26. Cai, J., Zhao, C., Du, Y., Zhang, Y., Zhao, M. and Zhao, Q. (2017). Comparative efficacy and tolerability of probiotics for antibiotic-associated diarrhea: Systematic review with network meta-analysis. United European Gastroenterology Journal, 6(2), pp.169-180.
  27. Johnston, B., Lytvyn, L., Lo, C., Allen, S., Wang, D., Szajewska, H., Miller, M., Ehrhardt, S., Sampalis, J., Duman, D., Pozzoni, P., Colli, A., Lönnermark, E., Selinger, C., Wong, S., Plummer, S., Hickson, M., Pancheva, R., Hirsch, S., Klarin, B., Goldenberg, J., Wang, L., Mbuagbauw, L., Foster, G., Maw, A., Sadeghirad, B., Thabane, L. and Mertz, D. (2018). Microbial Preparations (Probiotics) for the Prevention of Clostridium difficile Infection in Adults and Children: An Individual Patient Data Meta-analysis of 6,851 Participants. Infection Control & Hospital Epidemiology, 39(07), pp.771-781.
  28. Shen, N., Maw, A., Tmanova, L., Pino, A., Ancy, K., Crawford, C., Simon, M. and Evans, A. (2017). Timely Use of Probiotics in Hospitalized Adults Prevents Clostridium difficile Infection: A Systematic Review With Meta-Regression Analysis. Gastroenterology, 152(8), pp.1889-1900.e9.
  29. Newberry, S. (2012). Probiotics for the Prevention and Treatment of Antibiotic-Associated Diarrhea. JAMA, 307(18), p.1959.
  30. McFarland, L. (2015). Probiotics for the Primary and Secondary Prevention of C. difficile Infections: A Meta-analysis and Systematic Review. Antibiotics, 4(2), pp.160-178.
  31. CADTH (2018). Probiotics for antibiotic-associated diarrhea and Clostridium difficile infection: a review of clinical effectiveness.. [online] CADTH. Available at: [Accessed 31 May 2019].
  32. Allen, S., Wareham, K., Wang, D., Bradley, C., Sewell, B., Hutchings, H., Harris, W., Dhar, A., Brown, H., Foden, A., Gravenor, M., Mack, D. and Phillips, C. (2013). A high-dose preparation of lactobacilli and bifidobacteria in the prevention of antibiotic-associated and Clostridium difficile diarrhoea in older people admitted to hospital: a multicentre, randomised, double-blind, placebo-controlled, parallel arm trial (PLACIDE). Health Technology Assessment, 17(57).
  33. Goldenberg, J., Yap, C., Lytvyn, L., Lo, C., Beardsley, J., Mertz, D. and Johnston, B. (2017). Probiotics for the prevention of Clostridium difficile-associated diarrhea in adults and children. Cochrane Database of Systematic Reviews.
  34. Bakken, J. (2014). Staggered and Tapered Antibiotic Withdrawal With Administration of Kefir for Recurrent Clostridium difficile Infection. Clinical Infectious Diseases, 59(6), pp.858-861.
  35. Merenstein, D., Foster, J. and D’Amico, F. (2009). A Randomized Clinical Trial Measuring the Influence of Kefir on Antibiotic-Associated Diarrhea. Archives of Pediatrics & Adolescent Medicine, 163(8).
  36. Lau, C. and Chamberlain, R. (2015). Sa1792 Probiotics Are Effective At Preventing Clostridium difficile-Associated Diarrhea in Both Adult and Pediatric Populations: A Meta-Analysis.Gastroenterology, 148(4), pp.S-333-S-334.

Health PEI Physician Reviewers:

  • Dr. Greg German
  • Dr. Jeremy Beck
  • Dr. Bill Walker
  • Dr. Patrick McCrea
  • Dr. Michael Irvine
  • Dr. Matt Kutcher
  • Dr. Steve Scales

Approved: July, 2019

Next Review: 2024