Risks and Preventive Strategies for Clostridioides Difficile Transmission to Household or Community Contacts During Transition in Healthcare Settings

Ramin Asgary; Jessica A. Snead; Nabeel A. Wahid; Vicky Ro; Marina Halim; Judy C. Stribling


Emerging Infectious Diseases. 2021;27(7):1776-1782. 

In This Article

Abstract and Introduction


The burden of Clostridioides difficile infection (CDI) has greatly increased. We evaluated the risks for CDI transmission to community members after hospitalized patients are discharged. We conducted a systematic literature review in MEDLINE/PubMed, EMBASE, CINAHL plus EBSCO, Web of Science, Cochrane Library, and gray literature during January 2000–February 2019 and identified 4,798 citations were identified. We eliminated 4,554 citations through title and abstract screening; 217 additional citations did not meet full criteria. We reviewed texts for the 27 remaining articles qualitatively for internal/external validity. A few identified studies describing risks to community members lacked accurate risk measurement or preventative strategies. Primary data are needed to assess efficacy of and inform current expertise-driven CDI prevention practices. Raising awareness among providers and researchers, conducting clinical and health services research, linking up integrated monitoring and evaluation processes at hospitals and outpatient settings, and developing and integrating CDI surveillance systems are warranted.


Clostridioides (the genus name of this bacterium was changed from Clostridium to Clostridioides during 2018) difficile infection (CDI) is responsible for almost half a million infections and ≈29,000 deaths in the United States annually.[1] During 2000–2014, the number of hospitalizations from CDI increased from 134,518 to 361,945, and the financial contribution to inpatient healthcare expenditure increased from $0.5 billion to $3.9 billion.[2] Risk factors for CDI and colonization include older age, recent hospitalization, recent use of antimicrobial drugs, and use of proton-pump inhibitors.[3] Transmission of C. difficile occurs through the spread of spores primarily through environmental contamination, hands of healthcare personnel, and asymptomatic carriers.[4] Several well-established guidelines recommend strategies in the inpatient setting to prevent and treat CDI. Prevention methods strongly recommended in the guidelines within an acute-care setting include isolating patients with CDI in private rooms with private toilets, using gloves and gowns when entering rooms with CDI patients, using soap and water when entering or exiting a CDI patient room, and cleaning reusable equipment with a sporicidal disinfectant.[4] For treatment, the 2017 update by the Infectious Diseases Society of America (IDSA) and the Society for Healthcare Epidemiology of America (SHEA) recommends stopping causing antimicrobial drugs and using oral vancomycin or fidaxomicin, or intravenous metronidazole as a less preferred alternative, in most cases of CDI.[4]

Although classically believed to be a hospital-acquired infection, C. difficile has also proven to be a major community pathogen. Although the 2017 IDSA/SHEA update recognizes the role of CDI in the community, it gives no specific prevention strategies to use at home.[4] Community-acquired C. difficile might account for more than one third of total CDI cases, and patients tend to be younger and have less recent exposure to antimicrobial drugs and less exposure to healthcare settings than other persons who have CDI.[5,6]

Because many patients hospitalized for CDI are discharged before completing full-course treatment or complete resolution of diarrhea, a common conundrum is deciding what prevention strategies are effective to be recommended at home after discharge to prevent the spread of infection to household or community contacts. Although substantial data and consensus guidelines exist for effective prevention strategies in the inpatient setting, similar data appear more sparse in the community setting. In this study, we systematically assessed data regarding the rate and role of the spread of C. difficile from an index hospitalized patient to the patient's household members and community contacts. We also aimed to identify potential effective preventive strategies within the community.