Asymptomatic C Diff Complicates Care for High-Risk Patients

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Not every patient who carries Clostridioides difficile (C diff) gets sick, and distinguishing colonization from true infection in high-risk patients remains a challenge, a theme that came up at IDWeek 2026, held October 21-24 in Washington, DC.

C diff has different phenotypes, Senu Apewokin, MD, associate professor and founding director of the Transplant Infectious Disease Service at the University of Cincinnati College of Medicine, said in an interview with The American Journal of Managed Care^® that babies, for instance, can carry C diff with no symptoms at all. Apewokin said unpublished data from his group show that a large number of patients about to undergo stem cell transplantation have C diff, including the toxin and the gene, yet are asymptomatic.

That is why microbiology labs test only diarrheal stools, he explained. But diarrhea in these patients can have other causes, such as laxatives or chemotherapy.

“So some people would be asymptomatic had it not been the laxatives you gave them or the chemotherapy you gave them,” Apewokin said. “Do those patients need the same approach to C diff? Probably not, but we're not there yet. We don't know how to distinguish these patients, and so we approach them the same way.”

These patients can also be more vulnerable to infection itself. Chemotherapy can wipe out innate and humoral immunity, 2 protections against C diff, and his group's data show antibodies to the C diff toxin diminish during treatment, Apewokin said. In solid organ transplant recipients, including liver transplant recipients, liver disease and other factors can derange bile profiles, a major defense against C diff.

In a separate interview, Apewokin explained how hospital interventions can shift some patients from colonization to infection.²

These patients are often left out of clinical trials because their other conditions could confound the results, he said. Patients with severe neutropenia, for example, were excluded from the trials of fecal microbiota spores, live-brpk (Vowst; Aimmune Therapeutics), approved to prevent recurrence of C diff infection in adults after antibacterial treatment for recurrent infection.¹

“In fact, some of them need these interventions, but we don't know how these interventions would work in such patients,” Apewokin said.

As more clinical trials are done, he said he hopes more of these patients can be enrolled.

References

1. Vowst (fecal microbiota spores, live-brpk). Prescribing information. Aimmune Therapeutics. Accessed October 26, 2026. https://www.drugs.com/pro/vowst.html

2. McCrear S. Colonization vs infection: rethinking C. diff prevention. AJMC. October 25, 2026. Accessed October 26, 2026. https://www.ajmc.com/view/colonization-vs-infection-rethinking-c-diff-prevention