Clostridioides difficile (Formerly Known as Clostridium difficile; Also Called “C diff”)—Child Care and Schools

What is Clostridioides difficile ?

Clostridioides difficile is a spore- and toxin-forming bacterium that can cause diarrhea. Illness is often associated with recent antibiotic use.

What are the signs or symptoms?

• Children younger than 5 years, especially infants, commonly have C difficile bacteria or protein toxin in their stool without showing symptoms (called asymptomatic colonization ). It is unclear why so many children have the bacteria but do not become ill.

• Illness with C difficile is usually mild and causes nonbloody diarrhea, mild abdominal pain, nausea, loss of appetite, and low-grade fever.

• Signs of dehydration, including dry mouth, no tears, or no urine for 8 hours.

• Severe illness is rare and more likely to occur in immunocompromised children. Severe symptoms can include high fever, abdominal cramps, very ill appearance, very bloated abdomen, and occasional blood in the stool.

What are the incubation and contagious periods?

• Incubation period: Unknown. Illness typically develops 5 to 10 days after antibiotic therapy but can occur any time from the first day of treatment up to 10 weeks after completing antibiotics.

• Contagious period: Unknown. Infants are commonly colonized with the bacteria without causing illness in themselves or others.

How is it spread?

• Fecal-oral route: Contact with feces from an infected person, typically when the person contaminates their fingers and touches an object another person then touches. Children who have contact with the contaminated surface may place their fingers into their own or another person’s mouth.

• C difficile spores are also present in soil and the environment.

How do you control it?

• Use good hand-hygiene technique at all the times listed in Chapter 2 of Managing Infectious Diseases in Child Care and Schools: A Quick Reference Guide, 7th Edition , especially after toilet use or handling soiled diapers and before anything to do with food preparation or eating. Alcohol-based sanitizers do not kill C difficile spores. Soap and water will wash away the spores.

• Ensure proper surface disinfection that includes cleaning and rinsing of surfaces that may have become contaminated with stool (feces) with detergent and water and application of a US Environmental Protection Agency–registered disinfectant according to the instructions on the product label. For guidance on disinfectants, refer to Selection and Use of a Cleaning, Sanitizing, or Disinfecting Product in Chapter 8 of Managing Infectious Diseases in Child Care and Schools: A Quick Reference Guide, 7th Edition .

• Ensure thorough washing of raw fruits and vegetables.

• Ensure proper cooking and storage of food.

• Exclude infected staff members who handle food. See Safe Food Preparation and Service: Food Handlers in Chapter 2 of Managing Infectious Diseases in Child Care and Schools: A Quick Reference Guide, 7th Edition .

• Exclude for specific types of symptoms (see the section Exclude from educational setting?).

What are the roles of the educator and the family?

• A child or staff member with bloody diarrhea should receive a medical evaluation.

• There are multiple causes of bloody diarrhea. Until the cause of the diarrhea is identified, apply the recommendations for a child or staff member with diarrhea from any cause (see Diarrhea Quick Reference Sheet).

  • – Report the condition to the staff member designated by the early childhood education (ECE) program or school for decision-making and action related to care of ill children and staff members. That person, in turn, alerts possibly exposed family and staff members to watch for symptoms and notifies the Child Care Health Consultant.

  • – Ensure staff members follow the control measures listed in the section How do you control it?

  • – Do not allow a staff member with diarrhea to be involved with food handling or feeding of children.

  • – Report outbreaks of diarrhea (more than 2 children and/or staff members in the group) to the Child Care Health Consultant, who may report to the local health department.

• Outbreaks are uncommon in ECE settings.

• If you know a child or staff member in the program has C difficile

  • – Follow the advice of the child’s or staff member’s health professional.

  • – Report the infection to the local health department. The health professional who makes the diagnosis may not report that the infected child is a participant in an ECE program or school, and this could lead to delay in controlling the spread.

  • – Reeducate staff members about strict and frequent handwashing, diapering, toileting, food handling, and cleaning and disinfection procedures.

  • – In an outbreak, follow the directions of the local health department.

Note: The best way to prevent the spread of C difficile is by washing hands with soap and water. Using gloves is also an effective means of preventing spread, but not required. Gloves must be removed or changed after use. Perform hand hygiene after cleaning and disinfecting are done, even if gloves are worn.

Exclude from educational setting?

Yes, if

• The local health department determines exclusion is needed to control an outbreak.

• Stool is not contained in the diaper for diapered children.

• Diarrhea is causing “accidents” for toilet-trained children.

• Stool is more watery and frequency exceeds 2 stools above normal for that child during the time the child is in the program because this may cause too much work for EC educators and make it difficult for them to maintain sanitary conditions.

• There is blood or mucus in stool.

• The stool is all black.

• The child has a dry mouth, no tears, or no urine output in 8 hours (suggesting the child’s diarrhea may be causing dehydration).

• The child is unable to participate and staff members determine they cannot care for the child without compromising their ability to care for the health and safety of the other children in the group.

• The child meets other exclusion criteria (see Conditions Requiring Temporary Exclusion in Chapter 4 of Managing Infectious Diseases in Child Care and Schools: A Quick Reference Guide, 7th Edition ).

Readmit to educational setting?

Yes, when all the following criteria are met:

• Once diapered children have their stool contained by the diaper (even if the stools remain loose) and when toilet-trained children do not have toileting accidents

• Once stool frequency is no more than 2 stools above normal for that child during the time the child is in the program, even if the stools remain loose

• When the child is able to participate and staff members determine they can care for the child without compromising their ability to care for the health and safety of the other children in the group

Note: It is not necessary to demonstrate negative C difficile stool test results to be readmitted to the educational setting. C difficile is caused by antibiotic use; however, if the person has symptoms, C difficile is treated with a different antibiotic than the one that caused the infection.