Diagnosis and Management of Clostridioides difficile Infection

Primary Clinical Manifestations

Diarrhea, defined as three or more unformed stools in 24 hours, is the primary symptom of Clostridioides difficile infection, according to the World Journal of Emergency Surgery 1
Abdominal pain and cramps are common accompanying symptoms that may range from mild to severe 1
Abdominal distension, characterized by bloating and swelling of the abdomen, is a symptom of Clostridioides difficile infection 1
Fever, with a temperature >38.5°C, may indicate severe infection 3

Leukocytosis, with a WBC >15 × 10^9/L, suggests severe infection, as reported by the World Journal of Emergency Surgery and JAMA 3, 4
Elevated serum creatinine, ≥133 μM/L or ≥1.5 times premorbid level, indicates severe disease, according to the World Journal of Emergency Surgery and JAMA 3, 4
Hypoalbuminemia, with albumin <2.5 g/dL, is associated with severe disease 3
Elevated serum lactate may indicate fulminant disease with organ failure 3

Pseudomembranous colitis is a visible manifestation on endoscopy, characterized by yellowish plaques on the colonic mucosa, as described by the World Journal of Emergency Surgery 1
Toxic megacolon is a severe, potentially life-threatening complication with colonic dilation, according to the World Journal of Emergency Surgery 5, 3
Fulminant colitis is characterized by severe systemic inflammatory response, shock, and organ failure, as reported by the World Journal of Emergency Surgery and the Journal of Microbiology, Immunology and Infection 3, 6
Colonic perforation is a rare but life-threatening complication with high mortality, according to the World Journal of Emergency Surgery 3

Recent antibiotic use, particularly clindamycin, penicillins, cephalosporins, and fluoroquinolones, increases the risk of Clostridioides difficile infection, as reported by Praxis Medical Insights 2
Recent hospitalization or healthcare facility exposure increases the risk of exposure to C. difficile spores, according to Praxis Medical Insights 2
Advanced age is a risk factor for both acquisition and severe outcomes of Clostridioides difficile infection, as reported by Praxis Medical Insights 2
Immunocompromised status, including patients on glucocorticoids or chemotherapy, increases the risk of Clostridioides difficile infection, according to the World Journal of Emergency Surgery 5
Proton pump inhibitor use is associated with an increased risk of CDI, as reported by JAMA 7

Testing should only be performed on patients with clinically significant diarrhea (≥3 unformed stools in 24 hours) who are not taking laxatives, as recommended by the World Journal of Emergency Surgery 1
A two-step algorithm is recommended, starting with screening using GDH or NAAT (high sensitivity), followed by confirmation with toxin detection (higher specificity), according to the World Journal of Emergency Surgery and Praxis Medical Insights 1, 2
Perirectal swabs may be used for patients with severe CDI complicated by ileus who cannot produce stool specimens, as described by the World Journal of Emergency Surgery 1

Asymptomatic colonization occurs in 10-52% of certain populations, and testing and treatment are not recommended in these cases, as reported by JAMA and the World Journal of Emergency Surgery 4, 7
Post-infectious irritable bowel syndrome may occur in up to 35% of patients, but only 4.3% have persistent symptoms beyond three months, according to JAMA 7
"Test of cure" is not recommended, as 56% of patients may asymptomatically shed C. difficile spores for up to six weeks after successful treatment, as reported by JAMA 7
Recurrent symptoms may be due to either recurrent infection or post-infectious irritable bowel syndrome, and distinguishing between these is important but challenging, according to JAMA 7