Clostridium difficile infection (CDI), also known as C. difficile, is a gram-positive, rod-shaped bacteria. The spores survive in unfavorable conditions and are easily transmitted through contact with objects and humans. C. difficile infection causes colitis and diarrhea.
In this article:
- Nursing Process
- Nursing Assessment
- Nursing Interventions
- Nursing Care Plans
- Deficient Fluid Volume
- Deficient Knowledge
- Diarrhea
- Imbalanced Nutrition: Less than Body Requirements
Nursing Process
Since C. difficile infection is often related to a current antibiotic regimen that the patient is taking, it is critical to stop the current antibiotic causing C. difficile infection and replace it with another medication that will be less likely to cause this bacteria. Metronidazole may be given in combination with vancomycin to help treat severe C. difficile infection. Surgery may be required in severe cases if the colon is damaged.
Supportive treatment through proper nutrition and adequate fluid intake is necessary to prevent dehydration. Nurses play a vital role in managing symptoms of C. diff like diarrhea and abdominal pain. Nurses also instruct patients and staff on precautions to prevent the transmission of C. diff bacteria.
Nursing Assessment
The first step of nursing care is the nursing assessment, during which the nurse will gather physical, psychosocial, emotional, and diagnostic data. In this section we will cover subjective and objective data related to C. difficile.
Review of Health History
1. Note the patient’s general symptoms.
Diarrhea and colon inflammation (colitis) are the hallmark signs of C.difficile infection. Severe C. difficile symptoms include:
- Dehydration
- Severe abdominal pain and cramping
- Watery diarrhea occurring more than 10 times a day
- Nausea
- Fever
- Swollen abdomen
- Weight loss
- Loss of appetite
- Kidney failure
- Presence of blood or pus in the stool
2. Assess the patient’s bowel habits.
Signs and symptoms of mild to moderate C. difficile include watery diarrhea more than three times a day for more than one day with mild abdominal tenderness and cramping.
3. Ask the patient to recall the possible transmission.
Interview the patient on any incidents in which they may have contact with C. difficile through the following vectors:
- Food
- Water
- Soil
- Contaminated hands
- Human or animal feces
- Dirty surfaces
4. Do contact tracing.
C. difficile is highly contagious and can easily be transmitted through person-to-person contact and contaminated fomites. Some people with C. difficile bacteria who do not have symptoms are called carriers who can spread the infection to others.
5. Identify the risk factors.
Anyone can be infected by C. difficile. These factors increase the risk of CDI:
- Recent use of antibiotics
- Age 65 years old and above
- Recent hospital or nursing institution admission
- Compromised immune system
- History of C. difficile infection
- Inflammatory bowel disease
- Chronic kidney disease
- History of recent surgical procedure
6. Review the history of antibiotic use.
Antibiotic use is the most common cause of C. difficile infection. Antibiotics like clindamycin, penicillins, and cephalosporins tend to destroy healthy bacteria in the body along with the bacteria they are formulated to kill. Without these helpful bacteria, C. difficile can proliferate and cause infection.
Physical Assessment
1. Monitor the temperature.
C. difficile is an infection that can trigger fever as an immune response. A temperature of 38 degrees Celsius (100.4 degrees Fahrenheit) is frequently observed.
2. Observe the stool characteristics.
Frequent, foul-smelling, watery stools characterize CDI. Abdominal cramping and bloody or mucousy diarrhea indicate possible pseudomembranous colitis.
3. Monitor the hydration status.
Since CDI causes severe diarrhea, there is a higher risk of dehydration. Monitor for signs and symptoms, such as:
- General: Fatigue
- CNS: Headaches, lightheadedness, dizziness
- HEENT: Dry mouth and mucosa
- Cardiovascular: Tachycardia, low blood pressure
- Gastrointestinal: Loss of appetite (anorexia), nausea, vomiting, abdominal pain, abdominal distension
- Genitourinary: Oliguria, anuria, concentrated urine
- Integumentary: Dry skin, decrease in skin moisture, poor skin turgor
4. Watch out for signs of shock.
Serious complications like severe dehydration can arise from diarrhea related to CDI. It can result in the following:
- Alteration in mentation
- Lethargy
- Confusion
- Rapid heartbeat
- Fainting
- Electrolyte imbalances
- Hypotension
Diagnostic Procedures
1. Obtain stool for testing.
Patients should be tested for CDI if they experience three or more loose or unformed stools of sudden onset in 24 hours without any other known cause. In severe colitis, stools may test positive for blood. Fecal leukocytes (increased WBCs) are detected in roughly half of cases.
2. Detect C. difficile toxins.
Stool examination for toxigenic C. difficile bacillus or C. difficile toxins is the most effective diagnostic procedure for identifying C. difficile infection.
- Enzyme immunoassay (EIA) is the most used method for identifying bacteria-generated substances. Compared to earlier tests, this one is quicker and easier to complete. It is, however, less sensitive than prior techniques. Several stool samples could be required to obtain a reliable result.
- Polymerase chain reaction (PCR) is a recent technique for finding the toxin genes. It is the most accurate and precise test. Results are available in one hour and only require one stool sample.
- Stool culture is the most sensitive test, but the results may take days which may cause delays in the diagnosis and treatment of C. difficile.
3. Send blood samples for laboratory testing.
- Complete blood count may reflect increased WBC (leukocytosis).
- Electrolyte levels and serum creatinine assess signs of dehydration, fluid accumulation in the tissue (anasarca), and renal damage.
- Albumin levels are likely decreased (hypoalbuminemia).
- Serum lactate levels are increased (≥5 mmol/L) in severe cases.
4. Consider colon examination.
Imaging isn’t necessary to diagnose CDI. A sigmoidoscopy only visualizes the rectum and the lower portion of the colon, whereas a colonoscopy permits examining the entire colon and rectum. These tests can reveal whether there is inflammation, indicating inflammatory bowel disease or other concerns.
5. Assess for possible complications.
If the healthcare provider suspects potential complications of C. difficile, an abdominal X-ray or a computed tomography (CT) scan should be considered. It reveals images of the colon, showing bowel inflammation due to C. difficile infection. The scan identifies conditions such as:
- Bowel enlargement
- Bowel perforation
- Increasing colon wall thickness
- Toxic megacolon
Nursing Interventions
Nursing interventions and care are essential for the patients recovery. In the following section you’ll learn more about possible nursing interventions for a patient with C. difficile.
Treat the Infection
1. Discontinue the causative antibiotic.
Managing C. difficile starts with discontinuing the antibiotic that caused the compromised immune system.
2. Start antibiotics immediately.
Ironically, antibiotics are also used to treat C. difficile. Oral metronidazole treats mild-moderate C. difficile, while oral vancomycin or fidaxomicin treats severe cases. Teach the patient to take it as ordered. Fidaxomicin is effective in treating recurrent C. difficile.
3. Administer antibody-based therapy as ordered.
Human antibody bezlotoxumab (Zinplava) has been found to fight against C. difficile toxin B and lower the incidence of recurrent C. difficile infection in patients at a high risk of recurrence.
4. Expect no treatment for asymptomatic patients.
Despite a positive stool toxin test, asymptomatic patients should not receive antibiotics.
5. Implement contact precautions.
Patients with CDI should be on contact precautions. Advise the patient and visitors of the following:
- Wash hands with soap and water after every restroom use
- Emphasize hand washing before eating and contact with visitors
- Place the patient in an isolated room
- If diarrhea is present, only use a private bathroom dedicated to the patient
- Never share utensils and personal things with others
- Clean room and surfaces with bleach disinfectants
- Strict implementation of contact precautions (hand hygiene and wearing of gloves and gown)
- Hand sanitizer is not effective in killing C. difficile spores.
6. Treat the recurrent infection.
Once a patient experiences one relapse, the likelihood of a subsequent relapse rises. Repopulating the colonic flora and treating recurrent CDI is achieved using fecal microbiota transplantation (FMT). FMT replaces healthy intestinal bacteria in the colon via fecal enemas or infusion of donor feces through a nasoduodenal tube.
7. Encourage the patient to take probiotics as recommended.
Supplements or foods containing microorganisms known as probiotics are meant to help the body’s “good” bacteria grow to fight against C. difficile bacteria.
Manage Diarrhea and Complications
1. Promote hydration.
Fluid losses occur quickly with diarrhea. Severe dehydration may need to be treated with IV therapy. Encourage plenty of oral fluids as tolerated. Hydration can also prevent kidney failure.
2. Rest the colon.
During diarrhea, advise the patient to avoid certain foods such as dairy products, fatty foods, foods high in fiber, and foods with seasonings. Eating bland foods can help minimize stomach upset and irritation. The BRAT diet, which stands for “bananas, rice, apples, toast,” can reduce diarrhea.
3. Monitor the electrolytes.
Replenish the electrolytes and fluids lost due to diarrhea. Diarrhea can be life-threatening due to dehydration and electrolyte imbalances.
4. Give ORS as ordered for pediatric patients.
Oral rehydration solution (ORS), a mixture of pure water, sugar, and salt, should be used to treat diarrhea. Moreover, a 10–14 day course of dispersible 20 mg zinc tablets in addition to standard care reduces the length of diarrhea and improves results.
5. Provide skin care.
Frequent watery diarrhea irritates the perineal area and can cause skin breakdown, pressure ulcers, and other infections. The perineal area should be kept clean and dry and soothed with cool wipes. Apply barrier creams if the patient is incontinent.
Nursing Care Plans
Once the nurse identifies nursing diagnoses for C. difficile, nursing care plans help prioritize assessments and interventions for both short and long-term goals of care. In the following section you will find nursing care plan examples for C. difficile.
Acute Pain
C. difficile infection causes abdominal pain, cramping, and inflammation of the colon. Frequent diarrhea also causes burning and discomfort to the perianal area.
Nursing Diagnosis: Acute Pain
Related to:
- Diarrhea
- C. difficile infection
- Inflammatory process
- Skin breakdown
As evidenced by:
- Diaphoresis
- Distraction behavior
- Expression of pain
- Guarding behavior
- Positioning to ease the pain
- Protective behavior
Expected outcomes:
- Patient will report pain 2/10 or less using a pain scale.
- Patient will report an absence of cramping or abdominal tenderness.
- Patient will report relief from perianal discomfort.
Assessment:
1. Evaluate the patient’s pain and note its characteristics.
Abdominal pain and tenderness are expected with C. difficile. Closely monitor for abdominal swelling and distention which can signal a worsening in condition and complications such as toxic megacolon.
2. Assess the patient’s pain relief efforts.
This can help determine and evaluate effective pain relief methods as well as other interventions to try.
Interventions:
1. Administer specified medications as indicated.
Metronidazole and vancomycin are considered the mainstay antibiotic treatment options for C. difficile infection. NSAIDs like naproxen, ibuprofen, and indomethacin are contraindicated as they can increase the risk of C. difficile infection. Opioids are also found to increase the risk of severe disease, complications, longer hospital stays, and readmission.
2. Encourage the patient to use non-pharmacologic pain relief methods.
Instruct on the use of positioning, rest, distraction, breathing techniques, and heating pads to promote comfort.
3. Offer pain relief to irritated skin.
Frequent diarrhea from C. difficile can cause skin irritation to the perianal area. Offer comfort measures such as a Sitz bath and cooling ointments.
4. Involve the patient’s family in patient care.
Since C. difficile is highly contagious it can be an isolating illness. Instruct family members on proper precautions to prevent transmission but encourage contact to reduce feelings of pain and discomfort.
Deficient Fluid Volume
Patients with C. difficile infection experience watery diarrhea. In severe cases, diarrhea can occur as often as 15 times per day, causing severe dehydration.
Nursing Diagnosis: Deficient Fluid Volume
Related to:
- Diarrhea
- Disease process
- Insufficient fluid intake
- Loose watery stools more than 3 times per day
As evidenced by:
- Altered skin turgor
- Decreased blood pressure
- Dry skin
- Increased body temperature
- Increased heart rate
- Increased urine concentration
- Sudden weight loss
- Thirst
- Nausea
- Sunken eyes
- Weakness
Expected outcomes:
- Patient will remain free of any signs of dehydration and exhibit normal vital signs.
- Patient will experience no more than two loose stools per day.
- Patient will consume at least 500 mL of water per day if not contraindicated.
Assessment:
1. Assess for any signs of hypovolemia and dehydration.
Thirst, headaches, restlessness, and an inability to concentrate are the first signs of dehydration. Closely monitor for poor skin turgor, dry mucous membranes, dizziness, and weakness.
2. Assess and monitor vital signs.
A decrease in blood pressure occurs when the patient is dehydrated due to a decrease in blood volume. The heart rate and respiratory rate may increase in an attempt to compensate.
Interventions:
1. Monitor fluid intake and output.
Urine output is an accurate indicator of fluid balance and poor urine output along with a dark urine color can indicate dehydration.
2. Monitor the patient’s bowel movements.
Since patients with C. difficile infection often exhibit loose watery stools, it is essential to monitor the number of bowel movements and observe for complications such as blood or pus in the stool.
3. Provide oral or intravenous fluid replacement therapy.
Fluid replacement is essential to restore circulatory volume and correct electrolyte imbalances in patients with C. difficile infection. Continuous IV fluids will likely be ordered and the patient should be encouraged to consume water and other fluids.
4. Administer antibiotics as indicated.
Antibiotic use causes C. difficile, but it is also the required treatment. The offending antibiotic should be discontinued. Metronidazole is the recommended antibiotic to treat C. difficile and prevent diarrhea.
Deficient Knowledge
C. difficile infection is highly transmissible and inaccurate knowledge about the disease process, treatment, and prevention increases the incidence of transmitting the infection.
Nursing Diagnosis: Deficient Knowledge
Related to:
- Misinformation
- Inadequate access to resources
- Inadequate awareness of resources
- Inadequate information
- Inadequate interest in learning
- Inadequate knowledge of resources
- Inadequate participation in care planning
As evidenced by:
- Inaccurate follow-through of instructions
- Inaccurate statements about a topic
- Poor adherence to the care plan
- Worsening of symptoms
- Development of preventable complications
Expected outcomes:
- Patient will adhere to infection control interventions to prevent the spread of C. difficile.
- Patient will not experience a recurrence of C. difficile infection.
Assessment:
1. Assess the patient’s health literacy and readiness to learn.
Assessment of the patient’s learning needs, learning styles, and attitude toward learning is an essential part of the process of patient education.
2. Evaluate the patient and family’s understanding of C.difficile infection.
The patient and family members must be assessed to ensure an appropriate understanding of how C. difficile is spread.
Interventions:
1. Educate the patient about symptoms requiring immediate medical attention.
Educate on symptoms (loose watery stools, blood or pus in the stool, fever, and vertigo) that need to be reported right away to prevent progression and complications.
2. Educate the patient & family about infection control interventions.
Frequent handwashing before and after patient contact is essential in preventing the spread of C. difficile infection. Remind family members that alcohol-based hand sanitizers do not kill C. difficile spores.
3. Educate staff and visitors.
Patients with C. difficile are placed on contact precautions. A gown and gloves must be worn when entering their room and providing care and disposed of after.
4. Educate on possible surgical treatments.
Fecal transplants are an experimental treatment used to restore healthy bacteria into the patient’s colon from a donor. This treatment may be effective for patients with recurrent C. difficile infections.
5. Instruct on medications to prevent reinfection.
The patient may be instructed to continue taking probiotics that maintain the “good” bacteria in the gut.
Diarrhea
Diarrhea is the primary symptom of C. difficile infection and can occur up to 15 times per day and last until the infection has resolved.
Nursing Diagnosis: Diarrhea
Related to:
- Disease process
- Inflammatory process
- Infection
As evidenced by:
- Abdominal pain
- Abdominal cramping
- Bowel urgency
- Dehydration
- Hyperactive bowel sounds
- Loose, watery, foul-smelling stools
Expected outcomes:
- Patient will verbalize relief from abdominal cramping and experience decreased bowel urgency.
- Patient will report that stools are formed and brown without a foul odor.
Assessment:
1. Assess the patient’s pattern of defecation.
C. difficile infection causes frequent diarrhea that can occur up to 15 times per day and last days, weeks, or even months.
2. Assess the patient’s stool characteristics.
Patients experiencing diarrhea due to CDI produce stools that are loose, watery, or semi-formed in consistency with a greenish color.
3. Assess stool examination results.
A stool culture is performed to detect Clostridioides difficile toxin in the stool sample.
Interventions:
1. Monitor the patient’s intake and output and watch for signs of dehydration.
CDI causes dehydration due to excessive diarrhea, fever, and poor intake. A dehydrated patient may exhibit excessive thirst, decreased urine output, dry skin, dry mouth, lethargy, weakness, lightheadedness, and sunken eyes. Closely monitor the number of loose stools per day.
2. Encourage adequate fluid intake.
Since CDI causes dehydration due to excessive fluid loss and diarrhea, encourage adequate fluid intake. It is ideal to choose fluids that contain water, sugar, and salt like diluted fruit juices and broths.
3. Encourage the patient to avoid milk and dairy products except for yogurt.
Avoiding milk and other dairy products except for yogurts can help reduce the incidence of lactose intolerance and diarrhea, a common side effect of CDI. Yogurts containing live active probiotics can help repopulate the gastrointestinal tract with good bacteria and reduce gastrointestinal distress.
4. Assist in fecal microbiota transplantation (FMT).
In cases of recurrent CDI, FMT is utilized to help restore the patient’s intestinal flora using healthy donor feces to resolve the infection, manage symptoms, and prevent a recurrence.
5. Administer antibiotics as indicated.
Antibiotics Vancomycin, Fidaxomicin, and Metronidazole are indicated to help resolve the infection and reduce diarrhea in patients with CDI.
6. Encourage and assist with perineal hygiene.
Perineal hygiene is essential in preventing irritation of the perineal area and reducing the risk of further infection. If the patient is unable to keep themselves clean and dry, incontinence care must be performed for them.
Imbalanced Nutrition: Less than Body Requirements
C. difficile infection causes severe diarrhea, which results in dehydration and nutrient deficiency.
Nursing Diagnosis: Imbalanced Nutrition
Related to:
- Disease process
- Inflammatory process
- Nausea
- Vomiting
- Loss of appetite
- Abdominal discomfort
As evidenced by:
- Body weight below the ideal weight range for age and gender
- Muscle wasting
- Diarrhea
- Hyperactive bowel sounds
- Fatigue
- Abdominal pain/discomfort
Expected outcomes:
- Patient will be able to maintain BMI within standard parameters.
- Patient will remain free from any signs of dehydration and nutrient deficiency.
Assessment:
1.Assess the patient’s nutritional status.
Baseline data on the patient’s nutritional status can help with comparing new data to determine the progression of imbalanced nutrition or the effectiveness of the treatment regimen. CDI is associated with vitamin D deficiency, as low levels of this vitamin contribute to C. difficile colonization, inflammation, and toxin production.
2. Assess the patient’s fluid status.
CDI causes watery diarrhea up to 15 times per day, severe abdominal pain, fever, nausea, and loss of appetite, increasing the patient’s risk of developing dehydration.
3. Assess the patient’s weight and muscle loss.
Baseline weight comparison is critical to determine the progression of the condition and the effectiveness of the treatment regimen, as CDI can cause weight loss and muscle wasting due to dehydration, severe diarrhea, nutrient malabsorption, and loss of appetite.
Interventions:
1. Monitor laboratory values.
Laboratory tests like the 25-hydroxy vitamin D test are considered the most accurate test to measure vitamin D in the body. Patients with CDI also exhibit abnormal serum electrolyte levels, anemia, and hypoalbuminemia.
2. Encourage a high-fiber diet with high-nutrient foods.
Studies have shown that a diet rich in soluble fiber like oats, beans, citrus fruits, apple pulp, peas, barley, and carrots can help eliminate CDI faster. Also, incorporate foods rich in vitamins, potassium, calcium, and magnesium to replace lost electrolytes.
3. Encourage vitamin supplementation as indicated.
In cases of chronic CDI, vitamin supplementation with iron, zinc, and vitamins B12 and D may be indicated to ensure adequate nutrition.
4. Encourage probiotics.
Restoring healthy bacteria to the gut is essential to eradicate C. difficile. A probiotic supplement may be prescribed, or the patient can eat kefir, yogurt, and fermented foods like kombucha, sauerkraut, and tempeh.
5. Refer the patient to a dietitian.
Nutrient malabsorption is a known side effect of CDI. A dietitian can help plan an appropriate dietary regimen for the patient targeting specific nutrient deficiencies.
References
- Aberra, F. N. (2021, April 29). Clostridioides (Clostridium) difficile colitis: Practice essentials, background, pathophysiology. Diseases & Conditions – Medscape Reference. Retrieved March 2023, from https://emedicine.medscape.com/article/186458-overview
- C. difficile infection. Mayo Clinic. Updated: Aug. 27, 2021. From: https://www.mayoclinic.org/diseases-conditions/c-difficile/symptoms-causes/syc-20351691
- Centers for Disease Control and Prevention. (2022, September 7). Could you or your loved one have C. diff? Retrieved March 2023, from https://www.cdc.gov/cdiff/what-is.html
- Cleveland Clinic. (2019, April 24). Clostridioides difficile infection (C. diff.). Retrieved March 2023, from https://my.clevelandclinic.org/health/diseases/15548-c-diff-clostridioides-difficile-infection
- Clostridium difficile (C. diff) infection. NHS. Reviewed: 08 February 2022. From: https://www.nhs.uk/conditions/c-difficile/
- Gotter, A. (2021, August 30). What to eat when you have diarrhea: Foods to avoid and include. Healthline. Retrieved March 2023, from https://www.healthline.com/health/what-to-eat-when-you-have-diarrhea#_noHeaderPrefixedContent
- Khatri, M. (2022, November 14). C. Diff infection: Symptoms, causes, diagnosis, treatment, prevention. WebMD. Retrieved March 2023, from https://www.webmd.com/digestive-disorders/clostridium-difficile-colitis#091e9c5e80056718-3-8
- Lewis’s Medical-Surgical Nursing. 11th Edition, Mariann M. Harding, RN, PhD, FAADN, CNE. 2020. Elsevier, Inc.
- Mada, P. K., & Alam, M. U. (2022, May 1). Clostridioides difficile – StatPearls – NCBI bookshelf. National Center for Biotechnology Information. Retrieved March 2023, from https://www.ncbi.nlm.nih.gov/books/NBK431054/
- Mayo Clinic. (2021, August 27). C. difficile infection – Diagnosis and treatment – Mayo Clinic. Retrieved March 2023, from https://www.mayoclinic.org/diseases-conditions/c-difficile/diagnosis-treatment/drc-20351697
- Medical-Surgical Nursing: Concepts for Interprofessional Collaborative Care. 9th Edition. Donna D. Ignatavicius, MS, RN, CNE, ANEF. 2018. Elsevier, Inc.
- MedlinePlus. (n.d.). Stool C difficile toxin: MedlinePlus medical encyclopedia. MedlinePlus – Health Information from the National Library of Medicine. Retrieved March 2023, from https://medlineplus.gov/ency/article/003590.htm
- NHS inform: Scotland’s National Health Information Service. (2023, February 13). Clostridium difficile. Scottish health information you can trust | NHS inform. Retrieved March 2023, from https://www.nhsinform.scot/illnesses-and-conditions/infections-and-poisoning/clostridium-difficile
- What is C. diff? Centers for Disease Control and Prevention. Reviewed: September 7, 2022. From: https://www.cdc.gov/cdiff/what-is.html
- World Health Organization (WHO). (2017, May 2). Diarrhoeal disease. Retrieved March 2023, from https://www.who.int/news-room/fact-sheets/detail/diarrhoeal-disease
