Clostridioides difficile Infection and Pseudomembranous Colitis

Jaime Borkowski PharmD, BCPS, BCIDP Antimicrobial Stewardship Pharmacist

Northwestern Medicine Delnor Hospital
West Dundee, IL

Radhika Polisetty PharmD, BCPS, BCIDP, AAHIVP Professor/Clinical Specialist, Infectious Diseases

Northwestern Medicine Central DuPage Hospital
DuPage, IL

Rishita Shah, PharmD, BCPS Antimicrobial Stewardship Pharmacist

Northwestern Medicine Lake Forest Hospital
Lake Forest, IL

Jason E. Bowling, MD Assistant Professor

Department of Medicine/Division of Infectious Diseases
Director of Hospital Epidemiology, University Health System
UT Health San Antonio
San Antonio, TX

Revised Publication:
June 11, 2024
Original Publication:
March 21, 2018
Declarations of Conflicts of Interest:
  • Jason E. Bowling reports that he served as a consultant on an advisory board for Becton-Dickinson in May 2016 (related to skin antisepsis), outside the submitted work.
  • Jaime Borkowski declares no conflicts of interest.
  • Radhika Polisetty declares no conflicts of interest.
  • Rishita Shah declares no conflicts of interest.

Special thanks to Jason E. Bowling, MD for handling the 2018 iteration of the chapter and to Jaime Borkowski PharmD, BCPS, BCIDP, Radhika Polisetty PharmD, BCPS, BCIDP, AAHIVP, and Rishita Shah, PharmD, BCPS for updating the chapter in 2024.


Clostridioides difficile (C. difficile) is a gram-positive, spore-forming anaerobic bacillus that produces two large toxins, A and B, which cause diarrhea and colitis in susceptible patients whose normal colonic bacterial microbiota has been previously disrupted by prior antimicrobial treatment. Ref 73-1 Gerding DN, Johnson S. Clostridioides difficile infection, including pseudomembranous colitis. In: Loscalso J, Fauci A, Kasper D, et al, e... - You do not have permission to view this object.  For many years, rates of C. difficile infection in the United States continued to rise. Recent data show C. difficile rates in the U.S. have been decreasing since 2012. Ref 73-2 Azimirad M, Noori M, Raeisi H, et al. How does COVID-19 pandemic impact on incidence of Clostridioides difficile infection and exacerbatio... - You do not have permission to view this object.  This is largely due to improvements in infection control practices, antimicrobial stewardship efforts, and diagnostic testing. The SARS-Co-V-2 (COVID-19) pandemic that started spreading throughout the world in late 2019 and early 2020 resulted in increases in broad-spectrum antibiotic use and prolonged gut dysbiosis. Increases in infection control efforts in the height of the pandemic, however, seemed to have prevented significant increases in overall C. difficile infection rates. Ref 73-3 Granata G, Petrosillo N, Al Moghazi S, et al. The burden of Clostridioides difficile infection in COVID-19 patients: a systematic review a... - You do not have permission to view this object.  Ref 73-4 Baker MA, Sands KE, Huang SS, et al. The impact of COVID-19 on healthcare-associated infections. Clin Infect Dis. 2022;74(10):1748-1754. d... - You do not have permission to view this object.  Pseudomembranous colitis (PMC) is seen in about half of patients with symptomatic C. difficile infection and is characterized by formation of punctate pseudomembranes that can cover the entire colonic surface in severe cases. High-risk environments include acute care hospitals and long-term care facilities in which the use of antimicrobials is high, increasing the size of the susceptible population, and in which the environment is heavily contaminated by the spores of C. difficile, increasing the risk of patient contact with the organism. Good personal hand hygiene, gloving, barrier precautions, and thorough environmental cleaning to prevent transmission of the spores to the patient can accomplish prevention and control. C. difficile infection (CDI) can be most effectively prevented by reducing overall antimicrobial use and by limiting use of certain specific antimicrobials, such as clindamycin, third-generation cephalosporins, and fluoroquinolones. Implementation of a local antimicrobial stewardship program also encourages appropriate use of broader spectrum antimicrobials. Ref 73-5 Kociolek LK, Gerdine DN, Carrico R, et al.  Strategies to prevent Clostridioides difficile infections in acute-care hospitals: 2022 update... - You do not have permission to view this object.  Treatment of C. difficile infection is either oral vancomycin or fidaxomicin, and newer guidelines focus more on prevention of recurrence. The role of therapies such as toxin-binding monoclonal antibodies and fecal microbiota transplant is also becoming more delineated.