Clinical Study

From Symptoms to Solutions: What Are Current Testing Approaches to C. diff infection?

Clostridium difficile infection symptoms and solutions

Dr. Pallavi Upadhyay • Nov 30, 2025

November is Clostridioides difficile (C. diff) Awareness Month, a dedicated opportunity to highlight one of the most common and preventable healthcare-associated infections (HAI) within the United States. Each year, C. diff causes nearly half a million infections, resulting in abdominal cramps, severe diarrhea, prolonged hospitalizations, and in severe cases, life-threatening complications.1 Timely and accurate diagnosis of C. diff remains crucial for not only improving patient outcomes but also in minimizing infection transmission within the healthcare settings.

This article highlights the healthcare impact of C. diff infections and the critical role of targeted and appropriate diagnostics techniques in detecting and controlling C. diff infections.

What Is C. diff, and How Is It Transmitted?

C. diff is an anaerobic toxin-producing bacteria that invades the gastrointestinal tract, when gut microbiome is disrupted, most commonly after antibiotic use, resulting in a range of infectious diarrheal diseases known as antibiotic-associated diarrhea (AAD). In fact, C diff remains the most common causative agent of infectious AAD. Population group that are most susceptible are geriatric, hospitalized, immunocompromised, or those on extended antimicrobial therapy.2.3

Transmission of C. difficile primarily occurs via the “fecal–oral” route, meaning infection occurs when a person ingests the hardy spores shed in the stool of an infected or colonized individual. Since these spores are highly persistent, they spread easily in healthcare settings without strict hand-hygiene, cleaning, and infection prevention practices. The ingested spores can survive stomach acid, upon reaching the intestine, these spores germinate and produce active toxins triggering inflammation and disease in the colon. 4,5

Clinical symptoms can range from mild diarrhea to severe inflammation of the colon (aka colitis). In rare but extreme cases, infection can also lead to renal dysfunction, sepsis and threatening toxic megacolon. These risks and complications underscore the importance of rapid and accurate diagnosis for prompt infection prevention and control.4

Noteworthy, inappropriate, or excessive antibiotic use greatly increases the risk of C. diff infection. Studies have shown that more than half of hospitalized patients receive antibiotics during their hospital stay, and an estimated 30-50% of those antibiotic prescriptions are either empiric, unnecessary or inappropriate.4-6

How Is C. diff Diagnosed and Why Is Multi-Step C. diff Testing Approach Important?

Accurate diagnosis of C. diff is key in guiding prompt treatment and preventing the spread of infection. The following are three most common testing methods for C. diff diagnosis.7,8

  1. Glutamate Dehydrogenase (GDH) Antigen Test:  Screens for the presence of diff pathogen in stool samples. While the testing technique is rapid and cost-effective, the test does not confirm the toxin production and cannot differentiate between colonization and active infection.
  2. Toxin Enzyme Immunoassay (EIA): Detects active toxins A and B in patient’s stool sample. Unlike tests that only identify the presence of the pathogen, toxin EIAs confirm active infection in the patient. This test is critical to distinguish between diff colonizer (especially when asymptomatic) versus a patient with true toxin-mediated illness, thus helping clinicians make informed decisions and preventing unnecessary interventions. The main drawback of this test is its lower sensitivity compared with molecular tests and may actual infections (especially when toxin levels are low), thus increasing the risk of false-negative results, and negatively impact treatment outcomes.
  3. Nucleic Acid Amplification Tests (NAAT): Detects the genes that are responsible for toxin production. Main advantage of NAATs, especially PCR-based diff testing is the high sensitivity as well as the rapid turnaround time for the results, which help with early and accurate detection and timely treatment. While the test is extremely sensitive, the one limitation of the test is it cannot differentiate between colonization and active infection, making clinical context paramount in testing approach.

To support best testing practices and diagnostic accuracy, American College of Gastroenterology (ACG)9 and the Infectious Diseases Society of America (IDSA)10 recommend utilization of a multi-step testing algorithm, when specific clinical criteria for stool submission are not met:

Step 1. Initial screening via GDH antigen test or NAAT screens for the C diff organism,

Step 2. Toxin EIA confirms active toxin (A and B) production,

Step 3. NAAT (especially PCR) resolves discordant results. Testing should only be performed on unformed stool from symptomatic patients to avoid overdiagnosis of colonization.

 Incorporating two-step (GDH/NAAT + Toxin EIA) or three-step approach (GDH + Toxin EIA + NAAT) allows to accurately (with high sensitivity and specificity) distinguish between true infection and asymptomatic colonization, thereby improving diagnostic accuracy and lowering the chances of unnecessary treatment.

What Are the Treatment Recommendations For C. diff?

Once C. diff infection (CDI is confirmed, prompt treatment regimens are implemented to reduce further complications and infection spread.

The current IDSA guidelines recommend fidaxomicin as first-line treatment and vancomycin as second option for treatment for  CDIs, if fidaxomicin is unavailable. Metronidazole is recommended in the event of unavailability of afore-mentioned treatments. For recurrent (common in up to 30% cases) and sever CDIs, in addition to fidaxomicin and vancomycin, bezlotoxumab (monoclonal antibody) can be administered (especially in the immunocompromised and elderly patients). In recurrent cases, where standard therapy is unsuccessful, fecal microbiota transplantation is implemented which can help in restoring healthy gut microbiota.

In addition, FDA-approved live biotherapeutic products (e.g., Rebyota and Vowst) can be used as microbiome therapies. In severe, fulminant, and complicated cases (mainly for recurrent infections in high-risk patients), high-dose oral vancomycin, IV metronidazole, and rectal vancomycin can be required. Despite aggressive therapeutic interventions, life-threatening complications such as perforation, peritonitis, or uncontrolled toxic megacolons, can occur. Under such critical circumstances, an urgent surgical evaluation is needed to determine advanced/targeted treatment approach.10,11

Supportive care throughout the treatment is highly emphasized for timely recovery and effective patient management.

How Can C. diff Infections Be Prevented?

Infection prevention plays a critical role in protecting patients, healthcare workers, and communities from avoidable CDIs. The CDC recommends the following key points crucial in C diff infection prevention. 12

  • Washing your hands with soap and water is the best way to prevent the spread of C. diff from person to person.
  • Cleaning and disinfecting surfaces and laundry, especially if someone is sick in your home already, can reduce your risk of C. diff infection.
  • Any time antibiotics are used they can cause side effects, including C. diff infection. Take antibiotics only when you need them, and talk to a healthcare professional about the best treatment for your illness.

(For further information, visit: https://www.cdc.gov/c-diff/prevention/index.html)

Why Does C. diff Awareness and Testing Matter?

C. difficile remains a leading cause of HAIs in the United States. Raising awareness ensures that patients, clinicians, and caregivers recognize the early symptoms of CDIs, risk factors, and initiate the diagnostics and treatment plan accordingly. Since CDIs can cause a range of illnesses (from dehydration, colitis to sepsis), early detection through reliable laboratory tests can allow healthcare providers to initiate appropriate and targeted therapy before the disease severity or complications occur.4,5,13

Reducing the CDI burden requires collaborative efforts from clinicians, healthcare systems, and the community. Implementation and support of diagnostic and antibiotic stewardship by the healthcare providers, while patients advocating for appropriate antibiotic use and getting timely testing when symptoms arise, will ensure improved clinical outcomes.

In addition, with consistent awareness and evidence-based practices, CDIs can be significantly reduced. Adherence to prevention and control measures, such as hand hygiene, use of appropriate PPE (personal protective equipment), contact precautions, and sporicidal environmental disinfection, can substantially prevent CDIs, especially in healthcare settings.12-15

References

  1. CDC. Accessed 11-24-25
  2. Mada PK, Alam MU. Clostridioides difficile infection. [Updated 2024 Apr 10]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan.
  3. CDC. Accessed 11-24-25
  4. Schoyer E, Hall KK, Fitall E. Clostridioides difficile Infection. In: Hall KK, Shoemaker-Hunt S, Hoffman L, et al. Making Healthcare Safer III: A Critical Analysis of Existing and Emerging Patient Safety Practices [Internet]. Rockville (MD): Agency for Healthcare Research and Quality (US); 2020 Mar.
  5. Johanesen PA, Mackin KE, Hutton ML, Awad MM, Larcombe S, Amy JM, Lyras D. Disruption of the Gut Microbiome: Clostridium difficile Infection and the Threat of Antibiotic Resistance. Genes (Basel). 2015 Dec 21;6(4):1347-60.
  6. Macera M, Calò F, Onorato L, Di Caprio G, Monari C, Russo A, Galdieri A, Giordano A, Cuccaro P, Coppola N. Inappropriateness of Antibiotic Prescribing in Medical, Surgical and Intensive Care Units: Results of a Multicentre Observational Study. Life (Basel). 2021 May 24;11(6):475.
  7. Nicholson MR, Donskey CJ. Multistep Testing Algorithms for Clostridioides difficile Infection. JAMA. 2023 Sep 12;330(10):966-967
  1. ACG. Accessed 11-25-25
  2. Kelly CR, Fischer M, Allegretti JR, LaPlante K, Stewart DB, Limketkai BN, Stollman NH. ACG Clinical Guidelines: Prevention, Diagnosis, and Treatment of Clostridioides difficile Infections. Am J Gastroenterol. 2021 Jun 1;116(6):1124-1147
  3. IDSA. Accessed 11-25-25
  4. IDSA. Accessed 11-25-25
  5. CDC. Accessed 11-25-25
  6. CDC. Accessed 11-25-25
  7. Markantonis JE, Fallon JT, Madan R, Alam MZ. Clostridioides difficile Infection: Diagnosis and Treatment Challenges. Pathogens. 2024 Jan 27;13(2):118.
  8. WHO. Accessed 11-25-25

References

  1. CDC. Accessed 11-24-25
  2. Mada PK, Alam MU. Clostridioides difficile infection. [Updated 2024 Apr 10]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan.
  3. CDC. Accessed 11-24-25
  4. Schoyer E, Hall KK, Fitall E. Clostridioides difficile Infection. In: Hall KK, Shoemaker-Hunt S, Hoffman L, et al. Making Healthcare Safer III: A Critical Analysis of Existing and Emerging Patient Safety Practices [Internet]. Rockville (MD): Agency for Healthcare Research and Quality (US); 2020 Mar.
  5. Johanesen PA, Mackin KE, Hutton ML, Awad MM, Larcombe S, Amy JM, Lyras D. Disruption of the Gut Microbiome: Clostridium difficile Infection and the Threat of Antibiotic Resistance. Genes (Basel). 2015 Dec 21;6(4):1347-60.
  6. Macera M, Calò F, Onorato L, Di Caprio G, Monari C, Russo A, Galdieri A, Giordano A, Cuccaro P, Coppola N. Inappropriateness of Antibiotic Prescribing in Medical, Surgical and Intensive Care Units: Results of a Multicentre Observational Study. Life (Basel). 2021 May 24;11(6):475.
  7. Nicholson MR, Donskey CJ. Multistep Testing Algorithms for Clostridioides difficile Infection. JAMA. 2023 Sep 12;330(10):966-967
  8. ACG. Accessed 11-25-25
  9. Kelly CR, Fischer M, Allegretti JR, LaPlante K, Stewart DB, Limketkai BN, Stollman NH. ACG Clinical Guidelines: Prevention, Diagnosis, and Treatment of Clostridioides difficile Infections. Am J Gastroenterol. 2021 Jun 1;116(6):1124-1147
  10. IDSA. Accessed 11-25-25
  11. IDSA. Accessed 11-25-25
  12. CDC. Accessed 11-25-25
  13. CDC. Accessed 11-25-25
  14. Markantonis JE, Fallon JT, Madan R, Alam MZ. Clostridioides difficile Infection: Diagnosis and Treatment Challenges. Pathogens. 2024 Jan 27;13(2):118.
  15. WHO. Accessed 11-25-25

Dr. Pallavi Upadhyay

Director of Scientific and Clinical Affairs

Dr. Pallavi Upadhyay

Director of Scientific and Clinical Affairs

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Clostridium difficile infection symptoms and solutions

Dr. Pallavi Upadhyay • Nov 30, 2025

November is Clostridioides difficile (C. diff) Awareness Month, a dedicated opportunity to highlight one of the most common and preventable healthcare-associated infections (HAI) within the United States. Each year, C. diff causes nearly half a million infections, resulting in abdominal cramps, severe diarrhea, prolonged hospitalizations, and in severe cases, life-threatening complications.1 Timely and accurate diagnosis of C. diff remains crucial for not only improving patient outcomes but also in minimizing infection transmission within the healthcare settings.

This article highlights the healthcare impact of C. diff infections and the critical role of targeted and appropriate diagnostics techniques in detecting and controlling C. diff infections.

What Is C. diff, and How Is It Transmitted?

C. diff is an anaerobic toxin-producing bacteria that invades the gastrointestinal tract, when gut microbiome is disrupted, most commonly after antibiotic use, resulting in a range of infectious diarrheal diseases known as antibiotic-associated diarrhea (AAD). In fact, C diff remains the most common causative agent of infectious AAD. Population group that are most susceptible are geriatric, hospitalized, immunocompromised, or those on extended antimicrobial therapy.2.3

Transmission of C. difficile primarily occurs via the “fecal–oral” route, meaning infection occurs when a person ingests the hardy spores shed in the stool of an infected or colonized individual. Since these spores are highly persistent, they spread easily in healthcare settings without strict hand-hygiene, cleaning, and infection prevention practices. The ingested spores can survive stomach acid, upon reaching the intestine, these spores germinate and produce active toxins triggering inflammation and disease in the colon. 4,5

Clinical symptoms can range from mild diarrhea to severe inflammation of the colon (aka colitis). In rare but extreme cases, infection can also lead to renal dysfunction, sepsis and threatening toxic megacolon. These risks and complications underscore the importance of rapid and accurate diagnosis for prompt infection prevention and control.4

Noteworthy, inappropriate, or excessive antibiotic use greatly increases the risk of C. diff infection. Studies have shown that more than half of hospitalized patients receive antibiotics during their hospital stay, and an estimated 30-50% of those antibiotic prescriptions are either empiric, unnecessary or inappropriate.4-6

How Is C. diff Diagnosed and Why Is Multi-Step C. diff Testing Approach Important?

Accurate diagnosis of C. diff is key in guiding prompt treatment and preventing the spread of infection. The following are three most common testing methods for C. diff diagnosis.7,8

  1. Glutamate Dehydrogenase (GDH) Antigen Test:  Screens for the presence of diff pathogen in stool samples. While the testing technique is rapid and cost-effective, the test does not confirm the toxin production and cannot differentiate between colonization and active infection.
  2. Toxin Enzyme Immunoassay (EIA): Detects active toxins A and B in patient’s stool sample. Unlike tests that only identify the presence of the pathogen, toxin EIAs confirm active infection in the patient. This test is critical to distinguish between diff colonizer (especially when asymptomatic) versus a patient with true toxin-mediated illness, thus helping clinicians make informed decisions and preventing unnecessary interventions. The main drawback of this test is its lower sensitivity compared with molecular tests and may actual infections (especially when toxin levels are low), thus increasing the risk of false-negative results, and negatively impact treatment outcomes.
  3. Nucleic Acid Amplification Tests (NAAT): Detects the genes that are responsible for toxin production. Main advantage of NAATs, especially PCR-based diff testing is the high sensitivity as well as the rapid turnaround time for the results, which help with early and accurate detection and timely treatment. While the test is extremely sensitive, the one limitation of the test is it cannot differentiate between colonization and active infection, making clinical context paramount in testing approach.

To support best testing practices and diagnostic accuracy, American College of Gastroenterology (ACG)9 and the Infectious Diseases Society of America (IDSA)10 recommend utilization of a multi-step testing algorithm, when specific clinical criteria for stool submission are not met:

Step 1. Initial screening via GDH antigen test or NAAT screens for the C diff organism,

Step 2. Toxin EIA confirms active toxin (A and B) production,

Step 3. NAAT (especially PCR) resolves discordant results. Testing should only be performed on unformed stool from symptomatic patients to avoid overdiagnosis of colonization.

 Incorporating two-step (GDH/NAAT + Toxin EIA) or three-step approach (GDH + Toxin EIA + NAAT) allows to accurately (with high sensitivity and specificity) distinguish between true infection and asymptomatic colonization, thereby improving diagnostic accuracy and lowering the chances of unnecessary treatment.

What Are the Treatment Recommendations For C. diff?

Once C. diff infection (CDI is confirmed, prompt treatment regimens are implemented to reduce further complications and infection spread.

The current IDSA guidelines recommend fidaxomicin as first-line treatment and vancomycin as second option for treatment for  CDIs, if fidaxomicin is unavailable. Metronidazole is recommended in the event of unavailability of afore-mentioned treatments. For recurrent (common in up to 30% cases) and sever CDIs, in addition to fidaxomicin and vancomycin, bezlotoxumab (monoclonal antibody) can be administered (especially in the immunocompromised and elderly patients). In recurrent cases, where standard therapy is unsuccessful, fecal microbiota transplantation is implemented which can help in restoring healthy gut microbiota.

In addition, FDA-approved live biotherapeutic products (e.g., Rebyota and Vowst) can be used as microbiome therapies. In severe, fulminant, and complicated cases (mainly for recurrent infections in high-risk patients), high-dose oral vancomycin, IV metronidazole, and rectal vancomycin can be required. Despite aggressive therapeutic interventions, life-threatening complications such as perforation, peritonitis, or uncontrolled toxic megacolons, can occur. Under such critical circumstances, an urgent surgical evaluation is needed to determine advanced/targeted treatment approach.10,11

Supportive care throughout the treatment is highly emphasized for timely recovery and effective patient management.

How Can C. diff Infections Be Prevented?

Infection prevention plays a critical role in protecting patients, healthcare workers, and communities from avoidable CDIs. The CDC recommends the following key points crucial in C diff infection prevention. 12

  • Washing your hands with soap and water is the best way to prevent the spread of C. diff from person to person.
  • Cleaning and disinfecting surfaces and laundry, especially if someone is sick in your home already, can reduce your risk of C. diff infection.
  • Any time antibiotics are used they can cause side effects, including C. diff infection. Take antibiotics only when you need them, and talk to a healthcare professional about the best treatment for your illness.

(For further information, visit: https://www.cdc.gov/c-diff/prevention/index.html)

Why Does C. diff Awareness and Testing Matter?

C. difficile remains a leading cause of HAIs in the United States. Raising awareness ensures that patients, clinicians, and caregivers recognize the early symptoms of CDIs, risk factors, and initiate the diagnostics and treatment plan accordingly. Since CDIs can cause a range of illnesses (from dehydration, colitis to sepsis), early detection through reliable laboratory tests can allow healthcare providers to initiate appropriate and targeted therapy before the disease severity or complications occur.4,5,13

Reducing the CDI burden requires collaborative efforts from clinicians, healthcare systems, and the community. Implementation and support of diagnostic and antibiotic stewardship by the healthcare providers, while patients advocating for appropriate antibiotic use and getting timely testing when symptoms arise, will ensure improved clinical outcomes.

In addition, with consistent awareness and evidence-based practices, CDIs can be significantly reduced. Adherence to prevention and control measures, such as hand hygiene, use of appropriate PPE (personal protective equipment), contact precautions, and sporicidal environmental disinfection, can substantially prevent CDIs, especially in healthcare settings.12-15

References

  1. CDC. Accessed 11-24-25
  2. Mada PK, Alam MU. Clostridioides difficile infection. [Updated 2024 Apr 10]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan.
  3. CDC. Accessed 11-24-25
  4. Schoyer E, Hall KK, Fitall E. Clostridioides difficile Infection. In: Hall KK, Shoemaker-Hunt S, Hoffman L, et al. Making Healthcare Safer III: A Critical Analysis of Existing and Emerging Patient Safety Practices [Internet]. Rockville (MD): Agency for Healthcare Research and Quality (US); 2020 Mar.
  5. Johanesen PA, Mackin KE, Hutton ML, Awad MM, Larcombe S, Amy JM, Lyras D. Disruption of the Gut Microbiome: Clostridium difficile Infection and the Threat of Antibiotic Resistance. Genes (Basel). 2015 Dec 21;6(4):1347-60.
  6. Macera M, Calò F, Onorato L, Di Caprio G, Monari C, Russo A, Galdieri A, Giordano A, Cuccaro P, Coppola N. Inappropriateness of Antibiotic Prescribing in Medical, Surgical and Intensive Care Units: Results of a Multicentre Observational Study. Life (Basel). 2021 May 24;11(6):475.
  7. Nicholson MR, Donskey CJ. Multistep Testing Algorithms for Clostridioides difficile Infection. JAMA. 2023 Sep 12;330(10):966-967
  1. ACG. Accessed 11-25-25
  2. Kelly CR, Fischer M, Allegretti JR, LaPlante K, Stewart DB, Limketkai BN, Stollman NH. ACG Clinical Guidelines: Prevention, Diagnosis, and Treatment of Clostridioides difficile Infections. Am J Gastroenterol. 2021 Jun 1;116(6):1124-1147
  3. IDSA. Accessed 11-25-25
  4. IDSA. Accessed 11-25-25
  5. CDC. Accessed 11-25-25
  6. CDC. Accessed 11-25-25
  7. Markantonis JE, Fallon JT, Madan R, Alam MZ. Clostridioides difficile Infection: Diagnosis and Treatment Challenges. Pathogens. 2024 Jan 27;13(2):118.
  8. WHO. Accessed 11-25-25

References

  1. CDC. Accessed 11-24-25
  2. Mada PK, Alam MU. Clostridioides difficile infection. [Updated 2024 Apr 10]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan.
  3. CDC. Accessed 11-24-25
  4. Schoyer E, Hall KK, Fitall E. Clostridioides difficile Infection. In: Hall KK, Shoemaker-Hunt S, Hoffman L, et al. Making Healthcare Safer III: A Critical Analysis of Existing and Emerging Patient Safety Practices [Internet]. Rockville (MD): Agency for Healthcare Research and Quality (US); 2020 Mar.
  5. Johanesen PA, Mackin KE, Hutton ML, Awad MM, Larcombe S, Amy JM, Lyras D. Disruption of the Gut Microbiome: Clostridium difficile Infection and the Threat of Antibiotic Resistance. Genes (Basel). 2015 Dec 21;6(4):1347-60.
  6. Macera M, Calò F, Onorato L, Di Caprio G, Monari C, Russo A, Galdieri A, Giordano A, Cuccaro P, Coppola N. Inappropriateness of Antibiotic Prescribing in Medical, Surgical and Intensive Care Units: Results of a Multicentre Observational Study. Life (Basel). 2021 May 24;11(6):475.
  7. Nicholson MR, Donskey CJ. Multistep Testing Algorithms for Clostridioides difficile Infection. JAMA. 2023 Sep 12;330(10):966-967
  8. ACG. Accessed 11-25-25
  9. Kelly CR, Fischer M, Allegretti JR, LaPlante K, Stewart DB, Limketkai BN, Stollman NH. ACG Clinical Guidelines: Prevention, Diagnosis, and Treatment of Clostridioides difficile Infections. Am J Gastroenterol. 2021 Jun 1;116(6):1124-1147
  10. IDSA. Accessed 11-25-25
  11. IDSA. Accessed 11-25-25
  12. CDC. Accessed 11-25-25
  13. CDC. Accessed 11-25-25
  14. Markantonis JE, Fallon JT, Madan R, Alam MZ. Clostridioides difficile Infection: Diagnosis and Treatment Challenges. Pathogens. 2024 Jan 27;13(2):118.
  15. WHO. Accessed 11-25-25

Dr. Pallavi Upadhyay

Director of Scientific and Clinical Affairs

Dr. Pallavi Upadhyay

Director of Scientific and Clinical Affairs

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