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PubMed1992

Purification and characterization of an immunodominant 36 kDa antigen present on the cell surface of Clostridium difficile.

The 36 kDa antigen represents the major EDTA-extracted protein of Clostridium difficile strains belonging to electrophoretic group 2. Antibodies to this antigen are found in sera of patients with C. difficile-associated diarrhoea. The 36 kDa antigen was extracted from C. difficile C253 by EDTA and purified by gel filtration (Sephacryl S300) and ion exchange chromatography (DEAE-Trisacryl M). The molecular weight of the purified protein was 36 kDa as determined by SDS-PAGE, also in non-reducing conditions. By gel filtration, the molecular size appeared to be 72 kDa and was not modified by the presence of EDTA or SDS in the column buffer. Since IEF showed a single isoelectric form of pI 4.6, the protein could be a homodimeric molecule. Immunofluorescence demonstrated that the 36 kDa antigen was located on the surface of the C. difficile cell. Monospecific antiserum raised in rabbits reacted positively with the 36 kDa protein of most group 2 C. difficile strains isolated from antibiotic-associated diarrhoea (AAD) outbreaks in Italy and other European countries.

Antigens, Surface↗

PubMed2006

Lack of value of repeat stool testing for Clostridium difficile toxin.

Twenty years ago, Clostridium difficile was first established as a cause of pseudomembranous colitis and antibiotic-associated diarrhea.C. difficile diarrhea is a widely recognized problem in the inpatient setting, with potentially significant morbidity and mortality. Antibiotics, and some chemotherapy agents, can potentially cause C. difficile colitis/diarrhea. The most commonly implicated agents are ampicillin, clindamycin, and cephalosporins. Diarrhea during antibiotic therapy is common and may be caused by C. difficile. Testing for C. difficile differentiates diarrheas into C. difficile positive and C. difficile negative. C. difficile can be carried asymptomatically as normal gastrointestinal flora, and in adults who have received antibiotic therapy, carrier states can be as high as 46%. Hospitalized patients are often colonized with C. difficile. C. difficile produces 3 virulence factors: an enterotoxin (toxin A), a cytotoxin (toxin B), and a substance to inhibit bowel motility. Different tests can be used to detect these toxins. The most widely used test is the enzyme immunoassay (EIA) for toxin A, toxin B, or both. The EIA C. difficile toxin assay has sensitivity and specificity ranges of 50% to 90% and 70% to 95%, respectively. Diagnostically, C. difficile cell culture cytotoxin assay remains the gold standard with sensitivity and specificity of 93% and 89%, respectively. Because of lack of confidence of the EIA for C. difficile, some clinicians assume an initial negative result may represent a false-negative test, and repeat testing is often done. We evaluated the value of repeat stool testing for C. difficile toxin A and B by EIA in inpatients with nosocomial diarrhea on antibiotics.

Anti-Bacterial Agents↗

PubMed1994

Clostridium difficile: history of its role as an enteric pathogen and the current state of knowledge about the organism.

Clostridium difficile is the most frequently identified enteric pathogen in patients with antibiotic-associated diarrhea and colitis. It accounts for 10%-25% of all cases of antibiotic-associated diarrhea and virtually all cases of antibiotic-associated pseudomembranous colitis. Clinical features that distinguish infection with C. difficile from that due to many other enteric pathogens are hyperpyrexia, leukemoid reactions, toxic megacolon, pseudomembranous colitis, hypoalbuminemia, and chronic diarrhea. Factors important in the pathogenesis of disease are exposure to antibiotics, the presence of C. difficile in the patient's indigenous flora or acquisition of the organism from an environmental source, production of toxin A, and age-related susceptibility. The criterion standard for testing is the tissue culture assay; alternatives are culture and other methods of antigen detection including EIA, dot blot hybridization assay, and latex agglutination. The optimal drug for treatment is vancomycin; however, metronidazole is often used because it is less expensive. At present the main problems associated with C. difficile infection are treatment of patients with ileus, the management and prevention of nosocomial epidemics, and the management of repeated relapses.

Animals↗

PubMed1995

Acute gastroenteritis in three community-based nursing homes.

BACKGROUND: Acute gastroenteritis is a cause of considerable morbidity and mortality in the elderly population. A prospective assessment of acute diarrhea in three community-based long-stay homes is described. METHODS: A cohort study of acute gastroenteritis was performed in three community-based nursing homes, involving 572 residents over an 8-month period. Diarrhea cases were enrolled on the basis of the acute onset of loose stools of > or = 24 hours, as well as one of the following: a rectal temperature of > or = 100 degrees F, dehydration, positive occult blood, > or = 48 hours duration, or as a part of any outbreak. Stool cultures for Clostridium difficile were performed on all NH 1 patients. RESULTS: Fifty-three gastroenteritis cases were ascertained, consistent with incidence rates of 14.6, 36.4, and 6.7 cases/100 patient years in NH 1, NH 2, and NH 3, respectively. Requiring a Foley catheter (OR = 2.57; 95% CI, 0.93, 7.09) increased diarrhea risk. Six Clostridium difficile enteritis cases and an episode attributable to Aeromonas/Pleisomonas species were diagnosed. One C. difficile diarrhea case was imported from hospital to NH 1. Ten of 12 fecal excretors resided in close geographic clusters in NH 1, where a majority of the latter were mobile and incontinent of stool. CONCLUSIONS: Acute gastroenteritis was a common disease in the study nursing homes, for which specific risk factors were identified. A predominant role for Clostridium difficile in the taxonomy of nursing home diarrhea was suggested.

Acute Disease↗

PubMed2003

Prevalence and association of macrolide-lincosamide-streptogramin B (MLS(B)) resistance with resistance to moxifloxacin in Clostridium difficile.

Clostridium difficile remains the leading cause of nosocomially acquired diarrhoea. C. difficile usually exhibits resistance against beta-lactam antibiotics, whereas susceptibility to other drugs may vary. This study investigated the antimicrobial susceptibility of C. difficile to different antibiotics over a period of time and characterizes molecular mechanisms for resistance. One hundred and seventy-three toxigenic and 19 non-toxigenic C. difficile strains, recovered from patients in two university hospitals in Germany between 1986 and 2001, were investigated for their susceptibility to erythromycin, clindamycin, moxifloxacin, vancomycin and metronidazole employing the Etest. The genetic background for resistance was analysed using PCR and DNA sequencing. All strains were susceptible to vancomycin and metronidazole. Resistance to erythromycin, clindamycin and moxifloxacin was found in 27%, 36% and 12% of the tested strains, respectively. High-level resistance (MIC > 128 mg/L) against erythromycin and clindamycin was detected in 25% of the strains tested. Thirty-four of the macrolide-lincosamide-streptogramin B (MLS(B))-resistant strains carried the erythromycin resistance methylase gene. The results indicate an increase in the prevalence of resistance to MLS(B) and fluoroquinolone antibiotics in C. difficile. Fluoroquinolone resistance is associated with resistance to MLS(B) antimicrobials.

Anti-Bacterial Agents↗

PubMed2004

Elemental diet modulates the growth of Clostridium difficile in the gut flora.

BACKGROUND AND AIMS: Tube feeding is regarded as a risk factor for Clostridium difficile-associated diarrhoea. Recently, we reported that C. difficile toxin was frequently found in patients receiving an elemental diet. The present study was conducted to clarify whether elemental diets are associated with the growth of C. difficile in the gut flora. METHODS: C. difficile was cultured for 72 h in various concentrations of elemental diet containing 3% thioglycollate, and the growth rate or activity of C. difficile was evaluated by Gram stain or by measuring optical density at 560 nm. Faecal samples from 10 healthy adults were cultured in elemental diet + 3% thioglycollate. RNA was extracted from faeces with glass powder, which can eliminate PCR inhibitors, and mRNA of C. difficile toxin B was measured by reverse transcription PCR. RESULTS: Maximum OD560 value during culture in thioglycollate-containing elemental diet was 2.4 times higher than that in thioglycollate alone (P = 0.0163). Viability of C. difficile was decreased in thioglycollate but not in thioglycollate-containing elemental diet. Toxin B mRNA was detected in five faecal samples (50%) before culture and in all samples after culture. CONCLUSIONS: Our results suggest that an elemental diet can modulate the growth of C. difficile in the gut flora.

Adult↗

PubMed2003

Clinical correlation of toxin and common antigen enzyme immunoassay testing in patients with Clostridium difficile disease.

OBJECTIVE: The aim of the present study was to assess the correlation of Triage Micro Clostridium difficile Panel and toxin B cytotoxicity assay with the clinical diagnosis of C. difficile diarrhea. METHODS: The subjects evaluated were 98 patients with diarrhea for whom stool was submitted for testing for C. difficile. Clinical symptoms prompting evaluation, laboratory values, comorbid illness, and treatment outcomes that provided clinical insight into the etiology of the diarrhea were recorded. These data were then reviewed by two experienced clinical gastroenterologists who were blinded to the results of the Triage enzyme immunoassay and cytotoxin B assay. The final diagnosis of C. difficile diarrhea was based on the patient's clinical evaluation and symptoms, treatment, and subsequent outcome. RESULTS: Of 98 patients evaluated, 33 were diagnosed with C. difficile diarrhea by clinical criteria. The toxin B assay displayed 88% sensitivity and 100% specificity and positive predictive value. The toxin A component of the Triage Panel displayed 45% sensitivity but 98% specificity and 94% positive predictive value. The common antigen had 97% sensitivity and 95% negative predictive value. Among the 45 patients with only a common antigen detected, the most common diagnoses for diarrhea were chemotherapy-related, antibiotic-related diarrhea, and graft versus host disease. CONCLUSIONS: Our data show that both the Triage Micro C. difficile Panel and cytotoxin B for C. difficile have a high positive predictive value and negative predictive value for C. difficile diarrhea. The Triage Micro C. difficile Panel provides a reasonable alternative to the cytotoxin B assay in the assessment of clinically relevant C. difficile. The Triage Micro C. difficile Panel is less labor intensive and less expensive than cytotoxin B assay. The panel approach improves on the individual assay performances by increasing sensitivity and negative predictive value. When both common antigen and toxin A are positive, the likelihood of C. difficile diarrhea is high; conversely, when both results are negative, the likelihood of C. difficile diarrhea is low.

Adolescent↗

PubMed1997

Production of a complete binary toxin (actin-specific ADP-ribosyltransferase) by Clostridium difficile CD196.

A Clostridium difficile isolate was found to produce an actin-specific ADP-ribosyltransferase (CDT) homologous to the enzymatic components of Clostridium perfringens iota toxin and Clostridium spiroforme toxin (M. R. Popoff, E. J. Rubin, D. M. Gill, and P. Boquet, Infect. Immun. 56:2299-2306, 1988). The CDT locus from C. difficile CD196 was cloned and sequenced. It contained two genes (cdtA and cdtB) which display organizations and sequences similar to those of the iota toxin gene. The deduced enzymatic (CDTa) and binding (CDTb) components have 81 and 84% identity, respectively, with the corresponding components of iota toxin. CDTa and CDTb induced actin cytoskeleton alterations similar to those caused by other clostridial binary toxins. The lower level of production of binary toxin by CD196 than of iota toxin by C. perfringens was related to a lower transcript level, possibly due to a promoter region different from that of iota toxin genes. The cdtA and cdtB genes have been detected in 3 of 24 clinical isolates examined, and cdtB alone was found in 2 additional strains. One strain (in addition to CD196) was shown by Western blotting to produce CDTa and CDTb. These results indicate that some C. difficile strains synthesize a binary toxin that could be an additional virulence factor.

Amino Acid Sequence↗

PubMed1991

Nontoxigenic strains of Clostridium difficile lack the genes for both toxin A and toxin B.

A total of 39 toxigenic and 20 nontoxigenic strains of Clostridium difficile were tested for the presence of either toxin A or toxin B by the polymerase chain reaction (PCR). All toxigenic strains produced cytotoxin as assayed by using highly sensitive fetal lung fibroblasts and were positive for toxin A as well as toxin B in the PCR assay. All nontoxigenic strains failed to produce toxin and were negative in the PCR assay. This study shows that nontoxigenic strains of Clostridium difficile lack the toxin A as well as the toxin B gene.

Bacterial Proteins↗

PubMed1994

Rapid detection of toxigenic Clostridium difficile in fecal samples by magnetic immuno PCR assay.

Rapid detection of toxigenic Clostridium difficile in fecal samples was accomplished with the magnetic immuno PCR assay (MIPA). Elaborate DNA extraction techniques were unnecessary. First, we generated a mouse monoclonal antibody (MAb) reactive with only C. difficile, Clostridium sordellii, and Clostridium bifermentans. Then, magnetic beads were coated with the MAb, incubated with fecal samples to allow binding with C. difficile, extracted from the stool with a magnet, and processed in the PCR with primers specific for the toxin B gene. After optimizing MIPA by raising the number of PCR cycles from 35 to 40 and adding Chelex 100 to the PCR mixture, we found a sensitivity of 96.7%, a specificity of 100%, a positive predictive value of 100%, and a negative predictive value of 94.1% when compared with the culture of cytotoxic C. difficile from fecal samples. MIPA is a rapid, easy, and sensitive PCR method for demonstrating the presence of toxigenic C. difficile in stool samples and avoids the disadvantage of elaborate extraction of DNA from fecal samples.

Antibodies, Monoclonal↗

PubMed2002

Molecular fingerprinting of Clostridium difficile isolates: pulsed-field gel electrophoresis versus amplified fragment length polymorphism.

Two molecular fingerprinting techniques, pulsed-field gel electrophoresis (PFGE) and amplified fragment length polymorphism (AFLP), were used to investigate the epidemiological relatedness among Clostridium difficile isolates from suspected outbreaks in three general hospitals. Analysis by PFGE yielded inconclusive data as a result of extensive DNA degradation. Although this degradation could be prevented to a certain extent by the inclusion of thiourea in the electrophoresis buffer, the weak DNA banding patterns obtained in this way were still far from optimal. AFLP data were obtained by using fluorescently labeled PCR primers and analysis on an ABI PRISM automated DNA analysis platform. AFLP analysis yielded high resolution and highly reproducible DNA fingerprinting patterns from which the epidemiological relatedness among the isolates could easily be determined. AFLP results could be readily obtained within 24 h, whereas 3 to 4 days were routinely required to complete the lengthy PFGE protocol. AFLP clearly proved to be a much more fail-safe fingerprinting method for C. difficile isolates, especially for those isolates for which a standard PFGE procedure yielded inconclusive results due to DNA degradation.

Bacterial Typing Techniques↗

PubMedDate not supplied

Experimental Clostridium difficile enterocolitis in foals.

Despite empirical clinical association of infection with Clostridium difficile with colitis in horses, a causal link has not been confirmed. The objective of this study was to develop a model of C. difficile-associated diarrhea in foals with normal transfer of passive immunity. Nine 1-day-old pony foals were inoculated intragastrically with spores or vegetative cells of C. difficile. Five foals were challenged with spores, with 2 receiving 10(5) colony-forming units (CFUs) and concurrently 3 receiving 10(7) CFUs once daily for 3 days. Clindamycin was administered orally to disrupt gastrointestinal flora. A further 4 foals were challenged by orogastric administration of 10(10) CFUs of vegetative cells once daily for 3 days or until diarrhea developed. This group did not receive clindamycin. Spore and vegetative cell preparations were negative for toxins of C. difficile and common enteropathogens. Clinical signs varied from mild abdominal discomfort and pasty feces to colic and watery diarrhea in 8 of 9 foals. Four of 5 foals challenged with spores developed mild diarrhea, whereas all foals challenged with vegetative cells developed moderate to severe diarrhea. C. difficile was isolated from feces of all foals between 24 and 72 hours after inoculation and toxins A or B or both were detected in the feces of all foals by an enzyme-linked immunosorbent assay. We concluded that spores and vegetative cells of C. difficile are capable of colonizing the gastrointestinal tract, producing toxins, and inducing clinical signs similar to those encountered in naturally occurring cases. This study fulfilled Koch's postulates for C. difficile-associated diarrhea in foals and provides a model for consistent reproduction of the disease for future studies.

Animals↗

PubMed2001

Evaluating the CT diagnosis of Clostridium difficile colitis: should CT guide therapy?

OBJECTIVE: The purpose of this study was to further characterize the CT findings of Clostridium difficile colitis and to provide for the first time a diagnostic sensitivity, specificity, positive predictive value, and negative predictive value to help clinicians decide whether antibiotic treatment is warranted on the basis of CT findings while awaiting stool test results (which may take as long as 48 hr). MATERIALS AND METHODS: A retrospective review covering a 4-year period was performed of the charts and CT scans of 54 symptomatic patients with stool test results positive for C. difficile and of a control group of 56 patients with antibiotic-associated diarrhea with stool test results negative for C. difficile. RESULTS: At our institution, C. difficile colitis was explicitly diagnosed at CT in these patients with a sensitivity of 52%, specificity of 93%, positive predictive value of 88%, and negative predictive value of 67%. The sensitivity can be raised to 70% with no change in specificity with more rigid adherence to diagnostic criteria of colon wall thickening of greater than 4 mm combined with any one or more findings of pericolonic stranding, colon wall nodularity, the "accordion" sign, or otherwise unexplained ascites. CONCLUSION: Although routine CT screening of antibiotic-associated diarrhea is not advocated, the 88% positive predictive value of a diagnosis of C. difficile colitis in those who are scanned may merit consideration of treatment by clinicians on the basis of the CT results alone.

Adult↗

PubMed1994

Decrease in nosocomial Clostridium difficile-associated diarrhea by restricting clindamycin use.

OBJECTIVE: To report the investigation and effective control of a nosocomial epidemic of Clostridium difficile-associated diarrhea. DESIGN: Concurrent surveillance for identification of new nosocomial cases, retrospective case-control analysis, and hospital formulary control of antibiotic use. SETTING: University-affiliated Veterans Affairs Medical Center located in southwestern United States. PATIENTS: Hospitalized patients who developed diarrhea submitted stool specimens for cytotoxin assay. Patients who were positive for cytotoxin were compared with control patients without infection. MEASUREMENTS: Isolates of C. difficile were typed by restriction endonuclease analysis. Antimicrobial agent use from hospital pharmacy records and selected patient data from chart review were correlated with frequency of specific laboratory abnormalities. RESULTS: For 13 months, the monthly incidence of C. difficile infection averaged more than five times that for the previous 21 months. Stool specimens from 34 patients (59%) contained a single strain (restriction enzyme analysis type J7). Clindamycin was statistically associated with the epidemic as shown by the following: clindamycin use at our center compared with national normal values, clindamycin use for years before compared with during the epidemic, monthly use of clindamycin compared with monthly frequency of infection, frequency of infection in patients receiving clindamycin compared with that in patients receiving other antimicrobial agents, and amount of clindamycin used by infected patients compared with that used by control patients. Restricting clindamycin use led to a prompt disease in infection rate and the type J7 organisms. CONCLUSION: A nosocomial epidemic of C. difficile diarrhea was controlled by analysis of antibiotic use patterns and by subsequent restriction of clindamycin.

Arizona↗

PubMed1998

Acquisition of Clostridium difficile and Clostridium difficile-associated diarrhea in hospitalized patients receiving tube feeding.

BACKGROUND: Clostridium difficile is the most common infectious cause of nosocomial diarrhea, but its role in diarrhea associated with tube feeding has not been rigorously investigated. OBJECTIVE: To determine the incidence of C. difficile acquisition and C. difficile-associated diarrhea in tube-fed and non-tube-fed patients. DESIGN: Prospective cohort study. SETTING: A university-affiliated Veterans Affairs Medical Center. PATIENTS: 76 consecutive hospitalized, tube-fed patients and 76 hospitalized, non-tube-fed patients. The two cohorts were matched for age, unit location, duration of hospitalization before surveillance, and severity of illness. MEASUREMENTS: Incidence of C. difficile acquisition, incidence of C. difficile-associated diarrhea, and C. difficile restriction endonuclease analysis typing results. RESULTS: More tube-fed patients than non-tube-fed patients acquired C. difficile (15 of 76 patients [20%] compared with 6 of 76 patients [8%]; P=0.03) and developed C. difficile-associated diarrhea (7 of 76 patients [9%] compared with 1 of 76 patients [1%]; P=0.03). The mean proportion (+/-SD) of surveillance days with diarrhea was greater for tube-fed patients after the development of C. difficile-associated diarrhea than for tube-fed patients without this diarrhea (0.68+/-0.4 compared with 0.22+/-0.2 [95% CI for the mean difference, 0.08 to 0.84]). Postpyloric tube feeding (odds ratio, 3.14 [CI, 1.008 to 9.77]) and duration of surveillance (odds ratio, 1.08 [CI, 1.0009 to 1.16]) were risk factors for the acquisition of C. difficile. Nineteen restriction endonuclease analysis types of C. difficile were identified from 20 patients. CONCLUSIONS: Hospitalized, tube-fed patients, especially those receiving postpyloric tube feeding, are at greater risk for the acquisition of C. difficile and the development of C. difficile-associated diarrhea than are hospitalized, non-tube-fed patients. Clinicians should test for C. difficile in tube-fed patients with diarrhea.

Aged↗

PubMed2001

[Diagnosis of Clostridium difficile diarrhea: in search of a more efficient clinical focus].

BACKGROUND: The clinical parameters for the suspicion of Clostridium difficile infections, namely the use of antimicrobials and diarrhea, have a low predictive value for the diagnosis. AIM: To search other clinical variables and determine a clinical prediction model for (Clostridium difficile diarrhea. PATIENTS AND METHODS: All patients to whom a Clostridium difficile study was requested, were prospectively studied during 5 months. Clinical variables of these patients were registered. The diagnosis of Clostridium difficile was done using the cytotoxicity test in fibroblast cultures. RESULTS: Ninety two patients were analyzed and in 26, the diagnosis of Clostridium difficile was confirmed. A logistic regression model disclosed an age over 60 years old, the presence of mucus in the stools and a temperature over 37.8 degrees C in the previous 24 h, as significant predictors of the infection. The correlation of the model, between the predicted probability and the observed condition, was 81.5%. CONCLUSIONS: The presence of the clinical variables identified in this study are associated with a high probability of an infection by Clostridium difficile in patients with diarrhea and the recent use of antimicrobials.

Aged↗

PubMed2004

Clostridium difficile-associated colitis.

OBJECTIVE: To review the basic microbiology, pathogenesis of disease, and diagnosis of the nosocomial pathogen Clostridium difficile and to examine therapies recommended by the Canadian Task Force on Preventive Health Care. QUALITY OF EVIDENCE MEDLINE: was searched using MeSH headings. Controlled trials for therapy were sought, but case-control studies and observational reviews were included. MAIN MESSAGE: Clostridium difficile causes approximately 20% of cases of diarrhea associated with antibiotics, including clindamycin and the second- and third-generation cephalosporins. Diarrhea is usually mild, but can be severe; extreme cases develop toxic megacolon. Diagnosis is dependent on demonstrating presence of clostridial toxin in stool specimens or of pseudomembranes through sigmoidoscopy. First-line therapy for C. difficile diarrhea is restricted to metronidazole. Second-line therapy for treatment failure is vancomycin. For relapse, a second course of metronidazole is recommended; tapering courses of vancomycin and probiotics are used for multiple recurrences. CONCLUSION: Clostridium difficile is an important nosocomial pathogen requiring prudent use of antibiotics and strict infection-control policies to prevent large health care costs.

Anti-Bacterial Agents↗

PubMed2005

Colonization by Clostridium difficile of neonates in a hospital, and infants and children in three day-care facilities of Kanazawa, Japan.

The intestinal-carriage rates of Clostridium difficile in neonates hospitalized in the University Hospital's Center for Perinatal and Reproductive Health and in infants and children enrolled in two day-nurseries and a kindergarten were examined. Swab samples from the floors of these facilities were also analyzed to determine the extent of environmental contamination by this organism. C. difficile was found in the stool of only one of 40 neonates during the normal 1-week stay in the hospital after delivery. The isolate from the neonate was identical to that of her mother, as determined by PCR ribotyping, pulsed-field gel electrophoresis analysis, and toxin gene type, suggesting that the C. difficile-positive neonate acquired the organism from her mother rather than from the environment. By contrast, 47 (48.0%) of the 98 infants and children, comprising 50 enrolled in two day-nurseries who were >= 3 years old and 48 enrolled in a kindergarten who were 2-5 years old, carried C. difficile. The carriage rate in infants under 2 years of age was much higher (84.4%) than in children 2 years old and older (30.3%). When analyzed according to age group, the carriage rates were 100, 75.0, 45.5, 24.0, 38.5, and 23.5% in infants and children 0, 1, 2, 3, 4, and 5 years old, respectively. The observation that several children were colonized with the same type of C. difficile strain in each day-care facility, and that the floors of day-nursery A and kindergarten C were contaminated with C. difficile strains identical to those colonizing the intestines of children enrolled in those facilities suggests that cross-infection of C. difficile among children occurs through C. difficile-carrying children or their contaminated environments.

Carrier State↗