Uncovering a Hidden Risk: Alcohol Use Disorder Significantly Increases C difficile Infection Rates

A newly published study has unveiled a previously unrecognized link between alcohol use disorder (AUD) and an increased risk of Clostridioides difficile infection. Sparked by consistent clinical observations, this groundbreaking research explores a correlation not addressed in prior scientific literature, offering vital insights for infection preventionists (IPs) and health care providers.

To learn about the study, Infection Control Today^® (ICT^®) spoke with the study’s authors, Kelley Knapek, MPH, BSN, RN, CIC, CWON, infection prevention consultant at Kelley Knapek Consulting Services LLC, in Lafayette, Colorado; and Sara Reese, PhD, MPH, CIC, FAPIC, director of research at the Center for Research, Practice, and Innovation at the Association for Professionals in Infection Prevention and Control in Alexandria, Virginia.

The study originated from anecdotal findings within one health system, where patients diagnosed with C difficile frequently presented with alcohol-related conditions such as withdrawal.

“In talking with other infection prevention professionals in our area, we noticed that this was not unique to our facility,” Knapek said. “We [saw] it across the board, in rural and urban hospitals, wherever it might be. So, we wanted to see if there was some association, and looking at the literature, we couldn't find anything. We knew we had the opportunity to have a [huge] data set and see if this was related.

The research team expanded its scope to a multihospital analysis, examining data from 5 health care facilities across Colorado. Their aim was to determine whether alcohol use could be an independent risk factor for C difficile infection—beyond the traditionally recognized causes such as antibiotic exposure and hospitalization history.

Through their retrospective design, the study analyzed diagnostic codes indicating alcohol use across various degrees—from casual use to active withdrawal—and their relationship to C difficile diagnoses. The findings were striking: Individuals with any recorded alcohol-related diagnosis had a significantly higher risk of developing C difficile, and this risk increased further among those with active withdrawal or Clinical Institute Withdrawal Assessment (CIWA) orders in place.

The researchers highlighted several biological and behavioral mechanisms that might explain this correlation. Alcohol consumption alters gut microbiota, disrupts the intestinal barrier, and increases gut permeability—all factors known to contribute to gut dysbiosis, which in turn creates a favorable environment for C difficile overgrowth. These changes mimic the gut conditions caused by antibiotics, a well-established risk factor for C difficile infection.

These findings offer immediate practical implications for infection prevention. Clinicians and IPs could incorporate alcohol use history into risk assessments, enabling earlier screening and isolation precautions for potentially infectious patients. By recognizing AUD as a significant risk factor, healthcare providers may improve infection control efforts and limit C difficile transmission within clinical settings.

The study also highlighted several limitations. Because the research relied on existing electronic health record data, there were challenges in differentiating between C difficile colonization and active infection. Additionally, the vast scope of antibiotic data limited the researchers’ ability to control for every potential antimicrobial influence. The accuracy of race and ethnicity data was also variable, due to inconsistencies in documentation across medical records.

Despite these constraints, the results lay a solid foundation for future studies. The authors advocate for a prospective, multicenter study to more rigorously explore this association and possibly lead to protocol changes. Such research could classify AUD severity and test patients proactively, determining whether targeted screening and early intervention would reduce infection rates.

“We can look and have a higher suspicion for C difficile in patients who have a history of alcohol use," Reese, who is also a member of ICT's Editorial Advisory Board, said. “We can implement screening precautions earlier. We can implement tests there to get those patients on these contact precautions, or if someone uses additional special precautions, we can get them on earlier and prevent the spread. We know that patients who are not on precautions put those around them at risk for spreading status.”

Ultimately, this pioneering work raises awareness of alcohol’s overlooked role in gut health and health care-associated infections. It prompts a broader conversation about integrating lifestyle factors into infection prevention strategies. As research continues, the hope is that this association will influence clinical protocols and lead to more comprehensive care for vulnerable patient populations.

Reference

Ashmaig H, Russo A, Montero M, et al. Alcohol use as a risk factor for Clostridioides difficile. Am J Infect Control. 2023;53(4):422-425. doi:10.1016/j.ajic.2022.12.015